UK Inquiry Tracker

Damion Stanley Joseph Henson

Unknown

2013-0307 11 Dec 2013 Cumbria (South & East)

Concerns summary A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a facility not designed for drug rehabilitation.

Anthony Hughes

Unknown

2013-0352 9 Dec 2013 Liverpool

Concerns summary Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the specific case.

Millie Elizabeth Thompson

All Responded

2013-0356 6 Dec 2013 Manchester (South)

Concerns summary Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric life-saving kits.

Action taken summary The DfE confirms that paediatric first aid training is a statutory requirement for early years providers and is undergoing a consultation to reinforce the need for a first-aid trained staff …

Kirk Duboise

All Responded

2013-0329 6 Dec 2013 County Durham and Darlington

Concerns summary There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.

Keith Barton

All Responded

2013-0330 6 Dec 2013 Mid Kent and Medway

Concerns summary There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, hindering further specialist reviews.

Desmond Statton

Unknown

2013-0379 5 Dec 2013 Plymouth, Torbay & South Devon

Concerns summary The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.

Karl Doran

Unknown

2013-0328 5 Dec 2013 County Durham and Darlington

Concerns summary The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their activities.

Archibold Wellbelove

All Responded

2013-0324 4 Dec 2013 Warwickshire

Concerns summary The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware of footpath discontinuations.

Action taken summary Warwickshire County Council has brought forward a review of its night-lighting policy and decided to implement several changes at a footpath termination point. These include installing a dropped cross

Yuki Ivy Norman-Knight

All Responded

2013-0321 4 Dec 2013 Norfolk

Concerns summary Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.

Marjorie Evelyne Keogh

All Responded

2013-0325 4 Dec 2013 Leicester City and South Leicestershire

Concerns summary The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and non-compliant staircase furniture also posed safety issues.

Keith Thomas Graham

Unknown

2013-0327 4 Dec 2013 North and West Cumbria

Concerns summary Hospital procedures for seriously injured trauma patients require urgent review, specifically concerning summoning on-call clinicians, CT scanning protocols, and minimizing delays to theatre for surgery.

Horace Cottom

Unknown

2013-0351 3 Dec 2013 Manchester City

Agostino Costa

Unknown

2013-0322 3 Dec 2013 Inner North London

Concerns summary Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.

Abdullahi Sharif Abokar

All Responded

2013-0323 3 Dec 2013 Inner North London

Concerns summary Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.

Michael James Meyler

All Responded

2013-0320 2 Dec 2013 Manchester City

Concerns summary Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.

Karl Olof Nilsson

Unknown

2013-0332 2 Dec 2013 West Yorkshire (Western)

Concerns summary The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed to the fatal accident and previous injury incidents.

John William Tugwell

Unknown

2013-0319 1 Dec 2013 Surrey

Concerns summary The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.

Doris Phoebe Miller

Unknown

2013-0318 28 Nov 2013 Milton Keynes

Concerns summary Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.

Christopher Scott

Unknown

2013-0350 27 Nov 2013 Wiltshire & Swindon

Concerns summary The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility to the public.

Peter Jeffrey

All Responded

2013-0313 27 Nov 2013 Eastern District of London

Concerns summary Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.

Edna Elsie Mary Eden

All Responded

2013-0317 27 Nov 2013 Berkshire

Concerns summary Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.

Alan Stanfield Browning

Unknown

2013-0315 26 Nov 2013 Avon

Concerns summary A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.

Barry James Lewis

All Responded

2013-0314 26 Nov 2013 Manchester North

Concerns summary Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.

Christopher James Morgan

Historic (No Identified Response)

2013-0272 22 Nov 2013 Cambridgeshire

Cambridgeshire and Peterborough NHS Fou…

Concerns summary The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.

Garrett Joseph Franklin Elsey

Unknown

2013-0316 22 Nov 2013 Avon

Concerns summary An important HSE safety document concerning people in commercial waste containers is not widely known within the industry, indicating a need for an alert system to ensure awareness.