UK Inquiry Tracker

Ashley Bullard

Historic (No Identified Response)

2023-0024Deceased 11 Jan 2023

Bendpak Inc International Organization of Motor Veh… Liftmaster Ltd +5 more

Accident at Work and Health and Safety related deaths

Concerns summary (AI summary) Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety warnings, and inadequate recall of lifts with substandard gear ring bolts.

Andrew Brown

All Responded

2022-0371 21 Nov 2022

Metropolitan Police Service

Road (Highways Safety) related deaths

Concerns summary (AI summary) The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous guidelines on the "silent approach" and use of warning equipment.

Action Taken (AI summary) The MPS will include more specific wording in the MPS Police Driver and Vehicle Policy – Vehicle and Equipment SOP in relation to the use of warning equipment around vulnerable road users and pedestrians, and will undertake a review of the Policy.

Mena Terefi

Historic (No Identified Response)

2022-0166

NHS England West London Mental Health NHS Trust

Mental Health related deaths Suicide (from 2015)

Concerns summary (AI summary) Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.

Angela Maguire

Partially Responded

2022-0164

Kingston Hospital NHS Trust NHS England

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative care discussions.

Action Planned (AI summary) NHS England is actively implementing the NHS Long Term Plan to establish Imaging Networks across England by 2023, aiming for 70% of networks to reach a 'Maturing' level by 2024/5. This initiative will enable comprehensive regional sharing of patient imaging history and reports, with the existing Image Exchange Portal available in the interim.

Asher Sinclair

All Responded

2022-0272 4 Sep 2022

Clinical Commissioning Group NHS England

Child Death (from 2015) Community health care and emergency services related deaths

Concerns summary (AI summary) A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.

Noted (AI summary) NHS North West London has implemented a single children’s continuing care team with registered nurses and experienced managers providing a consistent service. A parental agreement has been developed which sets out expectations and responsibilities in regard to parental responsibility. NHS England highlights the resources provided by The National Tracheostomy Safety Project (NTSP) and notes the NWL's response addressing training, supervision and care packages. They also mention that all reports received are discussed by the Regulation 28 Working Group to share key learnings.

Christopher Ryan

All Responded

2023-0053Deceased 22 Jul 2022

South West London and St George’s Menta…

Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Action Planned (AI summary) The Trust details the policy regarding smoking, highlighting that it isn't permitted in buildings, carparks, grounds and gardens. The Trust has committed to undertaking a formal and comprehensive review of its 'Smoke Free' policy which has commenced and is due to be concluded in July 2023, which will also include how we ensure that practice reflects policy, particularly around leave.

Thomas Hoskin

Historic (No Identified Response)

2022-0115 22 Apr 2022

National Institute for Health and Care …

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.

Ketheeswaren Kunarathnam

All Responded

2022-0030 26 Jan 2022

Home Office

Mental Health related deaths Other related deaths State Custody related deaths Suicide (from 2015)

Concerns summary (AI summary) Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.

Action Taken (AI summary) The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.

Billy Warwick-Jones

Partially Responded

2021-0305 10 Sep 2021

Department for Transport Driver and Vehicle Licensing Agency General Medical Council

Community health care and emergency services related deaths Other related deaths Road (Highways Safety) related deaths

Concerns summary (AI summary) Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined with insufficient testing and guidance for older drivers, highlights a systemic road safety failure.

Noted (AI summary) The Department for Transport explains current driver licensing arrangements and guidance for medical professionals, noting age is not an automatic barrier to driving, but they encourage drivers to discuss concerns with medical professionals, and points to an older driver website. The GMC has contacted the Royal College of General Practitioners (RCGP) to raise awareness of the risks of confusion related to UTIs and driving among their members.

Kumbulani Mtombeni

All Responded

2021-0272 16 Aug 2021

Grassy Meadow Care Centre

Alcohol, drug and medication related deaths Care Home Health related deaths Suicide (from 2015)

Concerns summary (AI summary) Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.

Action Taken (AI summary) Care Outlook has implemented a digital care planning and monitoring system, will ensure all medication auditors and managers understand their obligation and have introduced a training program.

Bathsheba Shepherd

Historic (No Identified Response)

2021-0099 28 Mar 2021

Central and North West London NHS Found…

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths

Concerns summary (AI summary) Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.

Raphael Kolbe

All Responded

2021-0029 8 Feb 2021

Portland Hospital

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring fetal well-being.

Action Taken (AI summary) The Portland Hospital reiterated to staff that the primary responsibility of the midwife is fetal monitoring during epidural siting, and another midwife must assist the anaesthetist if necessary. They also installed a new reminder system for hourly 'fresh eyes' checks, highlighting overdue tasks in red on the patient status board.

Allan Gunnell

All Responded

2021-0026 29 Jan 2021

Marble Ideas Ltd

Other related deaths

Concerns summary (AI summary) The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable crystalline silica, potentially increasing their risk of developing severe diseases.

Disputed (AI summary) Marble Ideas Ltd disputes the coroner's report, stating they work in compliance with requirements for employers working with RCS. They highlight existing health and safety policies, external audits, and water-fed machinery used in stone processing.

Prince Fosu

All Responded

2020-0148 6 Jul 2020

Central & North West London NHS Foundat… Independent Monitoring Board

State Custody related deaths

Concerns summary (AI summary) Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.

Action Planned (AI summary) The IMB will deliver training to all immigration detention IMB members by the end of 2020, and require it for all future members with refresher training every three years. The training will focus on monitoring those in separation, raising concerns, and responding to allegations of abuse. The Trust is developing robust educational pathways within Offender Care and will develop a “train the trainer” programme to enable local sites to provide mental health awareness training routinely. The Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms and will be circulating it as a standalone document to all CNWL staff and to all partner agencies by the end of November 2020.

Bethan Harris

All Responded

2020-0133 22 Jun 2020

St. George’s University Hospitals NHS F…

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.

Action Taken (AI summary) The Trust has taken several steps including reinforcing the importance of accurate and contemporaneous record keeping, reviewing the administration of medication to patients, sharing learning, and ensuring patients are adequately monitored during their stay. Mandatory training will be ongoing.

Harold Uzomechina

Historic (No Identified Response)

2019-0351 21 Oct 2019

HMP Wormwood Scrubs

Alcohol, drug and medication related deaths State Custody related deaths

Concerns summary (AI summary) Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.

Matthew Williamson

All Responded

2019-0349 15 Oct 2019

West London Mental Health Trust

Mental Health related deaths

Concerns summary (AI summary) Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.

Action Taken (AI summary) The Trust has amended operational policies to include sections on strengthening family involvement and has mandated Carer Awareness and Triangle of Care training for Ealing PCMHS staff. They are also taking steps to establish a Carers Council.

Amir Siman-Tov

Historic (No Identified Response)

2019-0302 28 Aug 2019

CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office +2 more

State Custody related deaths

Concerns summary (AI summary) Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.

Sebastian Clark

Historic (No Identified Response)

2019-0196 13 Jun 2019

Royal College of Obstetricians and Gyna…

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Tarek Chowdhury

Historic (No Identified Response)

2019-0131 2 Apr 2019

HM Prison & Probation Service Home Office NHS England

Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths

Concerns summary (AI summary) There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

John Thorp

All Responded

2019-0067 26 Feb 2019

London North West University NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.

Action Taken (AI summary) The Trust has introduced a new, standardised prescription chart with a section for TED stockings, including a venous thromboembolism risk assessment. Nurses must sign and date the chart daily to confirm they have checked the fitting and skin integrity. Memos were sent to staff and the information circulated Trust-wide via newsletters and screen savers.

Sophie Bennett

Historic (No Identified Response)

2019-0476 13 Feb 2019

RCI RPFI

Care Home Health related deaths

Concerns summary (AI summary) The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.

Dennis Warner

Historic (No Identified Response)

2019-0470 28 Jan 2019

Care Quality Commission Royal United Hospital

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, and failed contact attempts.

Henry Curtis-Williams

All Responded

2018-0397 19 Dec 2018

Norfolk and Suffolk NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.

Action Planned (AI summary) The Trust will be using the case in learning via patient safety newsletter and practice education teams. The Trust issued an internal alert to inpatient wards directing reflection on processes where information is received from differing sources.

Patricia Chambers

Historic (No Identified Response)

2018-0350 4 Nov 2018

Shepherds Bush Medical Centre West London Mental Health Trust

Suicide (from 2015)

Concerns summary (AI summary) Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.