UK Inquiry Tracker

John William Wright

Historic (No Identified Response)

2013-0285 31 Oct 2013 London Inner North

North Middlesex University Hospital NHS…

Concerns summary A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.

Damion Anthony Andre Martin

Historic (No Identified Response)

2013-0280 30 Oct 2013 Liverpool

Rights and Responsibilities Group

Concerns summary Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.

Winston Llewellyn Johns

Historic (No Identified Response)

2013-0279 30 Oct 2013 Powys Bridgend and Glamorgan Valleys

Department of Health and Social Care Welsh Ambulance Service NHS Trust

Concerns summary Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.

Peter Clive Higson

All Responded

2013-0277 24 Oct 2013 Surrey

Concerns summary Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.

Action taken summary NHSBT disputes the coroner's concerns, stating that TRALI was unlikely given the clinical timeline and donor antibodies. They assert that benefits of platelet transfusions outweigh risks in such cases

Harold Elvidge

Historic (No Identified Response)

2013-0274 24 Oct 2013 Nottinghamshire

Nottingham University Hospitals NHS Tru…

Concerns summary A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.

Isabella Hope Hill

All Responded

2013-0281 23 Oct 2013 Liverpool

Liverpool Womens Hospital

Concerns summary Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.

Action taken summary The Trust has revised its UVC insertion guideline and proforma, enhanced staff education, clarified radiology service level agreements for neonatal X-rays to ensure a 60-minute turnaround, and provide

John Lansdowne

Unknown

2013-0360 23 Oct 2013 London Inner (North)

Concerns summary Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.

Jacqueline Allwood

Partially Responded

2013-0275 23 Oct 2013 London (Inner South)

Cator Medical Centre NHS Bromley Clinical Commissioning Group General Medical Council +1 more

Concerns summary The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.

Action taken summary NHS England outlines an action plan for the GP involved, requiring him to attend educational courses on DVT diagnosis/management and medical record keeping, and undertake a record-keeping audit by spe

Mark Stephen Smith

Historic (No Identified Response)

2013-0268 21 Oct 2013 London (North)

London Ambulance Service

Concerns summary Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.

Robert Wilkinson

All Responded

2013-0269 21 Oct 2013 County Durham & Darlington

Durham Constabulary

Concerns summary The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access to weapons.

Action taken summary Durham Constabulary states that face-to-face meetings will now be undertaken when they add value to firearms license reviews. They are also addressing weaknesses in record keeping by converting all ce

Lucy Kilvert

Historic (No Identified Response)

2013-0266 21 Oct 2013 Black Country

National Institution for Health and Cli…

Concerns summary A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.

Elsie Gibson

Historic (No Identified Response)

2013-0267 21 Oct 2013 South London

Bromley Council

Concerns summary The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading to a fatal injury.

Brian Belfield

Historic (No Identified Response)

2013-0270 21 Oct 2013 Cumbria (North and West)

Fell Runners Association

Concerns summary Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control and marshals, leading to a missing runner.

Jennifer Rushworth

Historic (No Identified Response)

2013-0264 18 Oct 2013 Manchester South

Stepping Hill Hospital

Concerns summary Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.

Elizabeth Aurora Kerr

Historic (No Identified Response)

2013-0276 18 Oct 2013 Manchester City

Greater Manchester Fire and Rescue Serv… Health and Safety Executive Ofgem +6 more

Concerns summary The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.

Brian Dorling and Philippine de Gerin-Ricard

All Responded

2013-0265 17 Oct 2013 London (Inner North)

Concerns summary Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists and motorists.

Action taken summary The Mayor of London plans further research into the use of unbordered blue surfacing on cycle routes to understand user perception and safety. He has also committed to upgrading existing …

Rosa Anderson

All Responded

2013-0263 17 Oct 2013 Liverpool

Aintree Hospitals NHS Trust

Concerns summary The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Action taken summary Aintree University Hospital has already implemented a discharge advice sheet for laparoscopic procedures, which is provided to all relevant patients prior to discharge. They are also implementing gene

Janet Richardson

Partially Responded

2013-0261 16 Oct 2013 Cumbria (North & West)

Cruise and Maritime Services Internatio… Redningsselskapet Newmarket Promotions Limited

Concerns summary The deceased fell into the sea during a rescue medical evacuation.

Action taken summary Newmarket Promotions Ltd's legal representatives state that the control of ship-to-ship medical evacuation procedures lies with the rescue authorities, not their client. They note the Coroner's recomm

John James Jackson

Historic (No Identified Response)

2013-0260 16 Oct 2013 Black Country

Department of Health and Social Care

Concerns summary An energy mint product contained dangerously high caffeine levels without adequate warnings or information on its packaging or online, posing a risk when consumed like sweets.

Yousef Shokri-Gharab

All Responded

2013-0239 14 Oct 2013 Liverpool

Concerns summary An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.

Action taken summary Mersey Care NHS confirms that the specific policy of concern regarding leave for informal patients has already been reviewed and updated. The Corporate Governance Team has completed reviews for 117 …

Frederick Davidson

Historic (No Identified Response)

2013-0258 14 Oct 2013 Surrey

Epsom and St Helier University Hospital… Department of Health and Social Care

Concerns summary Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.

Carol Ann Gibson

Historic (No Identified Response)

2013-0183 12 Oct 2013 Cheshire

Castlefields Health Centre NHS England

Concerns summary A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.

James Edward Mansfield

Historic (No Identified Response)

2013-0288 10 Oct 2013 Cambridgeshire (South and West)

Nuffield Road Medical Centre

Concerns summary Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.

Kuldip Singh Dhillon

Historic (No Identified Response)

2013-0254 8 Oct 2013 London (East)

Department for Transport

Concerns summary Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations by the Department of Transport.

Anthony Bernard Mcormick

Historic (No Identified Response)

2013-0255 8 Oct 2013 Manchester City

Consultant Physician and Gastroenterolo… East Cheshire NHS Trust

Concerns summary Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.