UK Inquiry Tracker

Molly Keen

Historic (No Identified Response)

2014-0336-wp24459 22 Jul 2014 Buckinghamshire

West Hertfordshire Hospitals NHS Trust

Concerns summary (AI summary) Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications of below-normal growth, no referral for further specialist opinion or scan was made.

Edward Devlin

Partially Responded

2014-0335 22 Jul 2014 County Durham & Darlington

Care UK HMP Durham National Offender Management Service +1 more

Concerns summary (AI summary) Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.

Action Planned (AI summary) Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence.

Marcin Stoga

All Responded

2014-0576 21 Jul 2014 Oxfordshire

HMP Bullingdon

Concerns summary (AI summary) Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.

Action Planned (AI summary) HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning from court for healthcare or self-harm issues.

Kathleen Cornthwaite

Historic (No Identified Response)

2014-0333 18 Jul 2014 Blackburn, Hyndburn & Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary (AI summary) The concerns text provided for this report was incomplete, preventing a summary of specific issues.

Joshua Brown

Partially Responded

2014-0289 17 Jul 2014 North East Kent

Care Quality Commission Department of Health and Social Care Kent and Medway NHS and Social Care Par…

Concerns summary (AI summary) The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.

Noted (AI summary) The Department of Health references existing guidance regarding information sharing with family members and mental capacity assessments in cases of suicide risk, but does not outline any new action being taken.

Michael Warren

Historic (No Identified Response)

2014-0330 17 Jul 2014 Berkshire

Bracknell Forest Borough Council Chartered Institute of Highways and Tra…

Concerns summary (AI summary) Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" inspections, increasing risk to road users.

Julie Robertson

Historic (No Identified Response)

2014-0326 16 Jul 2014 Essex

Southend University Hospital

Concerns summary (AI summary) Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care and readiness for surgery.

Silvia Taylor

Partially Responded

2014-0327 16 Jul 2014 Surrey

Bracknell Forest Council Harmoni South East Woking Borough Council

Concerns summary (AI summary) The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential intervention.

Action Taken (AI summary) Care UK reviewed and updated its policy regarding procedures when telephone calls to patients needing assessment by the out-of-hours GP service are unanswered.

Stephen Church

All Responded

2014-0331 15 Jul 2014 Berkshire

Berkshire Healthcare NHS Foundation Tru… British Transport Police Royal Berkshire NHS Foundation Trust +1 more

Concerns summary (AI summary) A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health Act assessment for a high-risk individual.

Action Planned (AI summary) Thames Valley Police is coordinating the re-drafting of an interagency joint working protocol for managing mental health in the Thames Valley area, taking into account the findings of the inquest. BTP updated its Manual of Guidance to ensure detainees are not left unsupervised until formally handed over to medical professionals, and that relevant mental health professionals are advised of the person's status. They also implemented training exercises and awareness programs for officers and control room staff on vulnerable persons, suicide prevention, and mental health issues incorporating lessons from the inquest. The Trust has finalised an interagency protocol and will be sending it out to all the agencies involved for consultation and will discuss the revised protocol with training for staff involved in crisis management to follow.

Ming Cheung

All Responded

2014-0332 15 Jul 2014 Coventry

Tesco Plc

Concerns summary (AI summary) An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing to the incident and near-misses.

Action Taken (AI summary) • Vegetation growth was cut back during the first week of August 2013 and will continue to be routinely checked at six-monthly inspections. • The SLL sign on the down line was moved from 4.9 meters to 3 meters on 8th August 2014. • The SLL sign on the up side remains at 3.4 meters from the track due to troughing at the 3 meter point, but its current location is considered appropriate.

Adam Williams

All Responded

2014-0324 14 Jul 2014 Staffordshire (South)

HMP Featherstone

Concerns summary (AI summary) Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential for further CCTV installation.

Action Taken (AI summary) HMP Featherstone now requires two healthcare staff to attend all health emergencies called over the radio. Duty Managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed by the Senior Management Team.

Shayla Walmsley

Historic (No Identified Response)

2014-0323 14 Jul 2014 London Inner (North)

Department of Health and Social Care Medicines and Healthcare Products Regul… Medtronic +1 more

Concerns summary (AI summary) Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices hinder investigations and timely safety interventions.

Elaine Jobe

All Responded

2014-0350 14 Jul 2014 Exeter & Great Devon

Devon Partnership NHS Trust

Concerns summary (AI summary) The report cites inadequate record keeping related to risk assessments and observation levels, a lack of training records for staff on risk assessment and observation implementation, and the need to review communication of patient status among staff.

Action Planned (AI summary) Devon Partnership NHS Trust has reviewed their policies and plans to complete additional actions, including reviewing risk assessments and delivering ward-based training on the updated policy, by January 2015. They will also conduct audits and review handover practice standards, with monitoring through quality assurance processes.

Maria Lopes

Partially Responded

2014-0325 11 Jul 2014 Surrey

Association of Anaesthetists of Great B… Basingstoke General Hospital Frimley Park Hospital NHS Trust +4 more

Concerns summary (AI summary) The report identifies multiple concerns, including consultant urologist on-call arrangements, supervision of out-of-hours urology trainees, recognition and treatment of sepsis, and the assessment of renal stones. There was also a lack of clarity and supervision regarding propofol infusion in ITU and a lack of understanding of Propofol-related infusion syndrome.

Noted (AI summary) Frimley Park Hospital acknowledges the coroner's concerns regarding urology on-call arrangements but states there are no specific national on-call guidelines for urology. They explain current practices and supervision of trainees, and note the Keogh recommendations will require a review of on-call services and development of an action plan.

Stuart Long

Historic (No Identified Response)

2014-0320 11 Jul 2014 Cornwall

Cornwall Council

Concerns summary (AI summary) Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a place of safety, exposing him to significant danger.

Georgina Taylor

Historic (No Identified Response)

2014-0328 9 Jul 2014 Manchester (North)

Department for Transport Highways Agency

Concerns summary (AI summary) Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle restraint protection or removal, posing a highway safety risk.

Thomas Smith

Historic (No Identified Response)

2014-0316 9 Jul 2014 Cardiff & the Vale of Glamorgan

Cwm Taf Health Board National Institute for Health and Clini… Prince Charles Hospital

Concerns summary (AI summary) Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.

Michael Harrison

Historic (No Identified Response)

2014-0317 9 Jul 2014 London (North)

Pinner and District Community Associati…

Concerns summary (AI summary) Inadequate measures to treat ice in the car park created an unsafe environment.

Andrew Hooper

Historic (No Identified Response)

2014-0319 9 Jul 2014 Exeter & Greater Devon

Devon Clinical Commissioning Group Drug and Alcohol Team Devon

Concerns summary (AI summary) Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to manage risks.

David Giles

All Responded

2014-0321 9 Jul 2014 Birmingham & Solihull

Home Office

Concerns summary (AI summary) The coroner raises concerns about the unrestricted availability of helium gas canisters, their standard size and lack of modified control valves, and the ease of accessing information on suicide methods using helium gas online.

Noted (AI summary) The Department of Health acknowledges the concerns regarding the sale of helium gas and references a previous response to a similar case. They provide a copy of that earlier reply.

Anthony Ponting

All Responded

2014-0332-wp24375 8 Jul 2014 Somerset (West)

Network Rail

Action Taken (AI summary) • The vegetation growth was cut back during the first week of August 2013. • Vegetation will continue to be routinely checked at six-monthly inspections. • The SLL sign on the down line was moved from 4.9 meters to 3 meters as recommended in the report.

Thomas Dixon

Historic (No Identified Response)

2014-0315 8 Jul 2014 Sunderland

City Hospitals Sunderland NHS Foundatio…

Concerns summary (AI summary) The report identifies failures to schedule timely appointments and a missing referral form. The coroner expressed concern that these issues may impact other patients, particularly in screening and follow-up, and suggested a review of the action plan addressing these concerns.

Muriel Naylor

Partially Responded

2014-0329 8 Jul 2014 Manchester (North)

Backhouse Jones Department for Transport Fentons +1 more

Concerns summary (AI summary) Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander Dennis Enviro 400 bus design may have contributed to passenger injury.

Action Planned (AI summary) The Department for Transport has raised the issue of bus seat design with bus manufacturers and plans to encourage them to adopt additional safety features. They also intend to raise the issue within the international technical group responsible for pan-European construction requirements.

Harold de Mello

All Responded

2014-0449 7 Jul 2014 London Inner (North)

Tower Hamlets Social Services

Concerns summary (AI summary) A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.

Action Planned (AI summary) Tower Hamlets Social Services has convened a Case Review meeting and commissioned an internal management review. They are developing a risk analysis tool, introducing an eco-mapping tool, and scheduling targeted training, with further changes planned due to the implementation of the Care Act 2015.

Stanley Bere

Partially Responded

2014-0339 4 Jul 2014 West Sussex

Salvation Army Villa Adastra Care Home

Concerns summary (AI summary) Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified or followed up by staff.

Action Taken (AI summary) Older Peoples Services has tightened reporting systems for falls and accidents, introduced a more secure system of archiving, and now ensures they have copies of district nurses' records for residents. The home manager regularly checks that issues are recorded and followed up.