UK Inquiry Tracker

Michael Telford

Historic (No Identified Response)

2014-0045 3 Feb 2014 Cumbria (North & West)

Cumbria County Council

Shaun Elliott

Historic (No Identified Response)

2014-0042 31 Jan 2014 Buckinghamshire

College of Policing

Concerns summary (AI summary) The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed a number of concerns and frustrations in regard to family liaison, and that the definition of 'High Risk' was not clearly applied.

William Kent

Historic (No Identified Response)

2014-0056 31 Jan 2014 Surrey

Guest Medical Medicines and Healthcare products Regul… St Peter’s and Ashford Hospitals

Concerns summary (AI summary) Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.

Ryan Chapman

Historic (No Identified Response)

2014-0048 31 Jan 2014 West Sussex

Sussex Partnership NHS Trust

Concerns summary (AI summary) Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

Gareth Slater

Historic (No Identified Response)

2014-0050 30 Jan 2014 Manchester (South)

Oldham Borough Council Pennine Care NHS Foundation Trust

Concerns summary (AI summary) Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.

Pamela Bailey

Historic (No Identified Response)

2014-0040 27 Jan 2014 South Yorkshire (West)

Sheffield Trust

Concerns summary (AI summary) Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.

Lillian Robinson

Historic (No Identified Response)

2014-0041 26 Jan 2014 Surrey

Surrey County Council

Concerns summary (AI summary) The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.

Elizabeth Turnbull

Historic (No Identified Response)

2014-0035 24 Jan 2014 South Yorkshire (East)

British Industrial Truck Association HM Principle Specialist Inspector

Concerns summary (AI summary) The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for excavator attachments.

Desrae Tucker

Historic (No Identified Response)

2014-0032 23 Jan 2014 Gwent

Aneurin Bevan Health Board

Concerns summary (AI summary) Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.

Paul Rogerson

Historic (No Identified Response)

2014-0029 22 Jan 2014 York

City of York Council North Yorkshire Fire and Rescue Service North Yorkshire Police

Concerns summary (AI summary) River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.

William Dowling & Victoria Rose

Historic (No Identified Response)

2014-0027 21 Jan 2014 Wiltshire & Swindon

Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Workin… +5 more

Concerns summary (AI summary) There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public safety.

Kyle Ashley Smith

Historic (No Identified Response)

2014-0028 21 Jan 2014 Manchester (West)

Longshoot Health Centre

Concerns summary (AI summary) An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.

John Malone

Historic (No Identified Response)

2014-0026 21 Jan 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary (AI summary) A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.

Christine Nutbeam

Historic (No Identified Response)

2014-0025 21 Jan 2014 Berkshire

St Peter’s Hospital Wexham Park Hospital

Concerns summary (AI summary) Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.

Julia Dell

Historic (No Identified Response)

2014-0021 17 Jan 2014 Cornwall

Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall

Concerns summary (AI summary) The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.

Jackie Scott

Historic (No Identified Response)

2014-0022 16 Jan 2014 North Northumberland

Indian Brasserie

Concerns summary (AI summary) Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.

James Stokoe

Historic (No Identified Response)

2014-0019 16 Jan 2014 Sunderland

Department of Health and Social Care

Concerns summary (AI summary) Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.

Russell James Felstead

Historic (No Identified Response)

2014-0016 14 Jan 2014 Manchester (South)

Care Quality Commission Stepping Hill Hospital Choice Support

Concerns summary (AI summary) Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.

Craig White

Historic (No Identified Response)

2014-0017 14 Jan 2014 South Lincolnshire

British National Formulary British Society of Gastroenterology Intensive Care Society +4 more

Concerns summary (AI summary) Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.

Barbara White

Historic (No Identified Response)

2014-0015 13 Jan 2014 Manchester (South)

Tameside General Hospital

Concerns summary (AI summary) Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.

Dr Edward Slaney

Historic (No Identified Response)

2014-0030 10 Jan 2014 West Yorkshire (East)

Ministry of Housing, Communities & Loca…

Concerns summary (AI summary) There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all highway users.

Mary Waldron

Historic (No Identified Response)

2014-0127 10 Jan 2014 Coventry

Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home +1 more

Concerns summary (AI summary) Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.

Jonathan Thorpe

Historic (No Identified Response)

2014-0006 8 Jan 2014 Manchester (South)

King Street Medical Centre

Concerns summary (AI summary) A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.

Andrew John Fallon

Historic (No Identified Response)

2014-0005 7 Jan 2014 Manchester (South)

Stockton NHS Foundation Trust

Concerns summary (AI summary) Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.

James Withers

Historic (No Identified Response)

2014-0004 7 Jan 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary (AI summary) Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.