UK Inquiry Tracker

Luke Lyons

All Responded

2013-0203 17 Sep 2013 Exeter & Greater Devon

Devon County Council

Action taken summary Devon County Council has used media channels and distributed letters to parishes and its website to alert road users to difficult travelling conditions. They confirm ongoing monitoring of the carriage

Peter Pattinson

All Responded

2013-0250 6 Sep 2013 Sunderland

European Care group

Concerns summary Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.

Action taken summary European Care Group has implemented new procedures for bed rail risk assessments (within 24 hours of admission and monthly review), a daily checking system for bed rail condition, and staff …

Labhuden Amarshi Vaghadia

All Responded

2013-0201 5 Sep 2013 Leicester City & South Leicestershire

Leicestershire Partnership NHS Trust

Concerns summary A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.

Action taken summary The Trust conducted extensive reviews of Mrs Vaghadia's death and current nursing practices, re-iterating vital communication principles through an implemented divisional strategy. They performed two

Karen Sutton

All Responded

2013-0223 4 Sep 2013 Leicester City & South Leicestershire

University Hospitals Leicester NHS Trust

Concerns summary Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.

Action taken summary The Trust has written to all consultants reminding them of their duty to contact specialist teams for patients with complex needs. They also plan to implement new software by April …

Jack William Payton

All Responded

2013-0220 30 Aug 2013 West Somerset

Avon and Somerset Constabulary

Concerns summary Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.

Action taken summary The Constabulary is commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to be completed by January 2014. Recommendations will be developed and con

Martin Leslie Brown

All Responded

2013-0209 29 Aug 2013 Gloucestershire

British Board of Agreement

Concerns summary The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.

Action taken summary The British Board of Agrément has revised paragraph 3.1 of Certificate 06/H120, removing the reference to rural roads and clarifying the product's suitability for highways with speed limits up to …

Dorothy Townley

All Responded

2013-0219 28 Aug 2013 Manchester (South)

Royal College of General Practitioners Royal College of Nursing

Concerns summary Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.

Action taken summary The Royal College of General Practitioners clarifies its role in providing training and professional development to GPs, outlining existing curriculum sections relevant to inter-professional communica

John Walker

All Responded

2013-0213 21 Aug 2013 West Sussex

Sussex Partnership NHS Trust

Concerns summary Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.

Action taken summary The Trust has revised clinical documentation for risk care planning and conducts regular audits to ensure standards are met. They have also altered fences throughout Langley Green Hospital to make …

Ann Margaret Spearing

All Responded

2013-0217 20 Aug 2013 Avon

REDACTED

Concerns summary Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.

Action taken summary Bristol CCG is re-procuring specialist mental health and learning disability services for more flexible, person-centred care. They have also implemented an enhanced advice and guidance scheme for GPs,

Derek Brierley

All Responded

2013-0244 20 Aug 2013 Manchester North

Pennine Acute Trust

Concerns summary The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.

Action taken summary The Trust has re-drafted and shared a pathway for managing urinary retention, making supra-pubic aspiration a first-line intervention. They have initiated a training program for staff on catheter inse

Ronald Ellwood

All Responded

2013-0222 15 Aug 2013 Staffordshire (South)

Queen’s Hospital

Concerns summary The provided concerns text is too truncated to identify specific safety issues.

Action taken summary Burton Hospitals NHS Foundation Trust disputes the need for fresh air from open windows in critical care, stating it would compromise patient safety and the existing air conditioning system designed …

Lucy Hannah Rose Bailey

All Responded

2013-0176 6 Aug 2013 Rutland & North Leicestershire

South Central Ambulance Service

Concerns summary Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.

Action taken summary South Central Ambulance Service has reviewed and updated the UK ambulance service clinical practice guidance on managing shoulder dystocia. The updated guidance was issued to Medical Directors of Ambu

Joseph Burrell

All Responded

2013-0194 5 Aug 2013 London (North)

Traffic and Harrows Network Management …

Concerns summary The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, making it unsafe to cross.

Action taken summary Harrow Council has completed the installation of a SCOOT system to synchronise traffic signals and is monitoring its performance. They have opened dialogue with Transport for London to review a …