UK Inquiry Tracker

George Leonard Parkes

Historic (No Identified Response)

2013-0252 4 Oct 2013 Birmingham and Solihull

University Hospitals Birmingham NHS Fou…

Concerns summary (AI summary) Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.

Jean James

Historic (No Identified Response)

2013-0207 4 Oct 2013 Cornwall

Rule 43 Archivist, Coroner Society of E… Office of the Chief Coroner Royal Cornwall Hospital

Concerns summary (AI summary) Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Walter Gordon Powley

All Responded

2013-0251 4 Oct 2013 Leicester City & South Leicestershire

Care Quality Commission Health and Safety Executive, Head of He… Registered Nursing Home Association

Concerns summary (AI summary) Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.

Action Planned (AI summary) The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection methodology checks high-risk areas, though their inspectors do check that radiators are covered but will often only sample a selection of people's rooms. HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the letter with local authority health and safety regulators and arrange for discussion at the next national local authority practitioner forum. The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue to advise members on risk assessments and safe radiator temperatures.

Ishmail Kubilay

Historic (No Identified Response)

2013-0248 3 Oct 2013 Hertfordshire

Department of Health and Social Care Ministry of Justice

Concerns summary (AI summary) The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.

Douglas Grey

Historic (No Identified Response)

2013-0253 3 Oct 2013 London (East)

Consumer Relations and Legal Affairs Floron Residential Home

Concerns summary (AI summary) Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising resident safety.

Michael Joseph Hirrell

All Responded

2013-0247 1 Oct 2013 Leicester City and South Leicestershire

Energy UK Npower Ofgem

Concerns summary (AI summary) Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to halt disconnection; and Ofgem was not informed of the death until the coroner's office notified them.

Action Planned (AI summary) OFGEM will monitor suppliers' performance regarding non-domestic disconnections and work with the coroner on reviewing the Safety Net provisions, considering how to promote them to non-domestic suppliers. They also provided context about existing protections for domestic consumers facing disconnection. Energy UK revised the Energy UK Safety Net to clarify protections for vulnerable domestic consumers using a shared non-domestic supply, publishing the updated version on their website. Signatories aim to implement required systems and processes by the end of 2014, with ongoing reviews and audits planned. Npower has briefed affected teams on process changes, organized face-to-face training with annual refresher, and introduced a trial period ceasing disconnection of shared commercial and domestic supplies during winter months. These measures are in addition to existing safeguards for vulnerable customers.

Rose Jean Coles

All Responded

2013-0246 27 Sep 2013 Avon

University Hospitals Bristol NHS Founda…

Concerns summary (AI summary) Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.

Action Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.

Jared William McDowall

All Responded

2013-0245 27 Sep 2013 Avon

University Hospitals Bristol NHS Founda…

Concerns summary (AI summary) Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.

Action Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.

Betty Grace Payne

Historic (No Identified Response)

2013-0242 26 Sep 2013 Carmarthenshire and Pembrokeshire

Carmarthenshire County Council County H… Pembrokeshire County Council Hall

Concerns summary (AI summary) Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire safety checks increase fire risks for the elderly.

Joan Farran

Historic (No Identified Response)

2013-0282 26 Sep 2013 Gateshead & South Tyneside

Safeguarding Adults Board Children, Adults & Families

Concerns summary (AI summary) The provided text is truncated and does not clearly state the specific concerns identified by the coroner.

Gwilym Pugh Jones

All Responded

2013-0239 25 Sep 2013 North Wales (East and Central)

Betsi Cadwaladr University Hospital Boa…

Concerns summary (AI summary) Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.

Action Taken (AI summary) • The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014.

Amna Umer Ahmed

Partially Responded

2013-0241 25 Sep 2013 London (Inner South)

British Cardiovascular Society Royal College of General Practitioners

Concerns summary (AI summary) Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.

Noted (AI summary) The Royal College of General Practitioners acknowledges the concerns, describes its role in GP training and standards, and references existing curriculum and resources related to cardiovascular disease and sudden adult cardiac death. It supports joint working to raise awareness among GPs and has consulted the British Heart Foundation.

David Selman

Historic (No Identified Response)

2013-0354 25 Sep 2013 Oxfordshire

South Central Ambulance Service

Concerns summary (AI summary) An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.

Jude Augustus Gordon

All Responded

2013-0237 24 Sep 2013 South Yorkshire (West)

Department of Health and Social Care

Concerns summary (AI summary) Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.

Noted (AI summary) The Department of Health acknowledges the concerns, noting existing work on a national early warning score (NEWS) and the use of computerised systems in some Trusts. However, it states that there are no current plans to mandate computerised EWS systems nationally due to IT infrastructure limitations, and emphasizes the importance of local training.

Linda Hudson

Historic (No Identified Response)

2013-0243 24 Sep 2013 County Durham and Darlington

Tees, Esk and Wear Valleys NHS Foundati…

Concerns summary (AI summary) Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.

Michael Sweeney

All Responded

2013-0236 23 Sep 2013 London North (Inner)

London Ambulance Service Metropolitan Police

Concerns summary (AI summary) Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.

Disputed (AI summary) The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance Service. The Medical Director will encourage the adoption of shared terminology and increase awareness in emergency departments. The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and raised the issue of terminology with the national Ambulance Service Mental Health Working Group, which will issue a position statement after consulting the Royal College of Psychiatrists. They will also share their response with the Pan London Emergency Department Consultants Group.

Sally King

Historic (No Identified Response)

2013-0196 23 Sep 2013 Milton Keynes

Care Quality Commission Milton Keynes General Hospital

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

Yvonne Sydney Annie Perry

Historic (No Identified Response)

2013-0195 23 Sep 2013 Milton Keynes

Care Quality Commission Milton Keynes General Hospital

Concerns summary (AI summary) A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access to electronic hospital notes, impeding effective treatment.

Joan Mary Jones

All Responded

2013-0234 20 Sep 2013 Leicester City and South Leicestershire

Manor Residential and Nursing Care Home

Concerns summary (AI summary) Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.

Action Taken (AI summary) Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged a consultant to arrange a meeting to address outstanding questions.

Tripta Rani Kumar

Historic (No Identified Response)

2013-0235 19 Sep 2013 London Eastern

Queen’s Hospital

Concerns summary (AI summary) A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.

Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet

Historic (No Identified Response)

2013-0347 19 Sep 2013 Birmingham & Solihull

SENAT, Birmingham Woman’s Hospital and …

Concerns summary (AI summary) Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.

Daniel Onley

Partially Responded

2013-0208 19 Sep 2013 Gloucestershire

Camp Village Trust Care Quality Commission Gloucestershire Social Services

Concerns summary (AI summary) Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.

Action Taken (AI summary) The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and requested regular audits.

Neil Richard Clark

Historic (No Identified Response)

2013-0231 17 Sep 2013 Birmingham and Solihull

Jurys Inn Birmingham

Concerns summary (AI summary) A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory Care Unit unnoticed, subsequently taking his own life.

Alva Jullien

Historic (No Identified Response)

2013-0232 17 Sep 2013 Manchester South

Stockport NHS Foundation Trust

Concerns summary (AI summary) A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by mouth' decision was made with insufficient evidence.

Margaret Theresa Corrigan

Historic (No Identified Response)

2013-0233 17 Sep 2013 Manchester South

Stockport NHS Foundation Trust

Concerns summary (AI summary) Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.