UK Inquiry Tracker

Edwin Thompson

Historic (No Identified Response)

2014-0542 22 Dec 2014 Gateshead & South Tyneside

Quality Care Commission South Tyneside Council

Concerns summary A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.

Samia Shara

Historic (No Identified Response)

2014-0548 19 Dec 2014 London Inner (West)

North West Collaborative Clinical Commi… NHS England

Concerns summary There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.

Thomas Jenkins

Historic (No Identified Response)

2014-0543 19 Dec 2014 Powys, Bridgend & Glamorgan Valleys

Cwm Taf University health Board Medicine & Accident and Emergency Cwm t…

Concerns summary Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN service, led to delayed ulcer assessment.

John Stabler

Historic (No Identified Response)

2014-0552 18 Dec 2014 Central Lincolnshire

National Offender Management Service HMP North Sea Camp Nottinghamshire Healthcare NHS Trust +2 more

Concerns summary The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.

Rebecca Overy

Historic (No Identified Response)

2014-0535 17 Dec 2014 Nottinghamshire

Department of Health and Social Care

Concerns summary An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.

Simon Satchwell

Historic (No Identified Response)

2014-0537 12 Dec 2014 Hertfordshire

Foreign, Commonwealth & Development Off…

Concerns summary Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult supervision, differing from UK safety standards.

Elaine Giles

Historic (No Identified Response)

2014-0529 5 Dec 2014 South Lincolnshire

Peterborough and Stamford NHS Trust

Concerns summary An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.

Freda Owens

Historic (No Identified Response)

2014-0559 27 Nov 2014 Blackpool & Fylde

Croft House Rest Home Blackpool Teaching Hospital NHS Foundat… Lancashire Teaching Hospitals NHS Found…

Concerns summary There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.

Richard Turner

Historic (No Identified Response)

2014-0513 25 Nov 2014 Norfolk

FALCON CRANE HIRE LIMITED

Concerns summary Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.

Sandra Bodrozic

Historic (No Identified Response)

2014-0560 24 Nov 2014 London Inner (North)

Camden & Islington NHS Foundation Trust

Concerns summary Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.

Lara Mamula

Historic (No Identified Response)

2014-0508 24 Nov 2014 Isle of Wight

Isle of Wight NHS Trust Isle of Wight Ambulance Service

Concerns summary The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.

Martin McCabe

Historic (No Identified Response)

2014-0505 20 Nov 2014 Powys, Bridgend & Glamorgan Valleys

Cwm Taf Health Board

Concerns summary The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.

Gladys Smith

Historic (No Identified Response)

2014-0502 17 Nov 2014 West Yorkshire (East)

Moorfield House Surgery St Armands Court Residential Care Home Leeds Community Healthcare NHS Trust +1 more

Concerns summary No specific safety concerns were detailed in the provided text.

John Wright

Historic (No Identified Response)

2014-0494 13 Nov 2014 Nottinghamshire

Rail Accident Investigation Branch Network Rail Office of the Rail Regulator +1 more

Concerns summary Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. There was also a concern about balancing hearing protection with the ability to hear oncoming trains.

Patricia Mellor

Historic (No Identified Response)

2014-0491 12 Nov 2014 Nottinghamshire

Medicines and Healthcare Product Regula… National Institute for Health and Care … National Patient Safety Agency +1 more

Concerns summary Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.

Lorraine Sheridan

Historic (No Identified Response)

2014-0496 12 Nov 2014 Black Country

Sandwell Metropolitan Borough Council

Concerns summary Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.

David Ince

Historic (No Identified Response)

2014-0497 12 Nov 2014 Preston & West Lancashire

North West Ambulance Service NHS Trust

Concerns summary Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.

Neophytos Constantinou

Historic (No Identified Response)

2014-0498 12 Nov 2014 London Inner (North)

Royal Free London NHS Foundation Trust Chalfont Road Surgery

Concerns summary Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.

Beryl Walters

Historic (No Identified Response)

2014-0489 11 Nov 2014 Black Country

College of Emergency Medicine National Institute for Clinical Excelle…

Concerns summary Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.

Mary Hallworth

Historic (No Identified Response)

2014-0487 11 Nov 2014 Manchester (South)

Home Instead Senior Care

Concerns summary A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.

Amar Majid

Historic (No Identified Response)

2014-0495 11 Nov 2014 Coventry

Coventry City Council

Concerns summary Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.

Mark Hancock

Historic (No Identified Response)

2014-0484 10 Nov 2014 Manchester (South)

Priory Group

Concerns summary Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for managing patients requiring admission when beds are unavailable.

Barry Horrocks

Historic (No Identified Response)

2014-0492 7 Nov 2014 West Yorkshire (East)

National Offender Management Service NHS England

Concerns summary A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.

Colin Ireland

Historic (No Identified Response)

2014-0493 7 Nov 2014 West Yorkshire (West)

HMP Manchester

Concerns summary Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.

Alan Evans

Historic (No Identified Response)

2014-0472 29 Oct 2014 Powys, Bridgend & Glamorgan Valleys

Powys Highways Department

Concerns summary The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk requiring double white lines and slim-line catseye replacement.