UK Inquiry Tracker

Helena Farrell

All Responded

2014-0309 3 Jul 2014 Cumbria (South & East)

Cumbria County Council Cumbria Partnership NHS Foundation Trust

Concerns summary Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified qualifications and professional oversight.

Beryl Brinkman

All Responded

2014-0314 2 Jul 2014 Manchester (North)

Rochdale Metropolitan Borough Council

Concerns summary Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.

Hywel Hughes

Partially Responded

2014-0311 2 Jul 2014 North West Wales

North Wales Constabulary Home Office Security Industry Authority

Concerns summary Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.

Liam Hardy

Historic (No Identified Response)

2014-0307 2 Jul 2014 London (South)

South West London and St George’s Menta…

Concerns summary The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.

Farres Ikken

Historic (No Identified Response)

2014-0310 2 Jul 2014 London (North)

Department of Health and Social Care

Concerns summary Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.

Henry Marsh

All Responded

2014-0306 2 Jul 2014 London (North)

Department of Health and Social Care

Concerns summary The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.

Ronald Perry

All Responded

2014-0302 2 Jul 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.

Albert Flynn

All Responded

2014-0308 2 Jul 2014 Manchester (South)

HC-One

Concerns summary Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.

Gary Daltry

All Responded

2014-0295 2 Jul 2014 North Wales (East & Central)

Denbighshire County Council

Concerns summary An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.

Esther Jones

Historic (No Identified Response)

2014-0296 2 Jul 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.

Sindy Woodhall

All Responded

2014-0292 1 Jul 2014 Manchester (North)

Department for Business Innovation and … Trading Standards Institute Public Health England +1 more

Concerns summary A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that poses a health risk.

John Adams

Historic (No Identified Response)

2014-0293 1 Jul 2014 Brighton & Hove

National Patient Safety Agency National Research Ethics Service Brighton and Sussex University Hospitals

Concerns summary No specific concerns or systemic failures were detailed in the provided text.

Jake Hardy

Historic (No Identified Response)

2014-0305 30 Jun 2014 Manchester (West)

Youth Justice Board Ministry of Justice HM Youth Offenders Institute Hindley +1 more

Concerns summary Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.

Dayani Chauhan-Ahmed

All Responded

2014-0287 30 Jun 2014 Leicester City & South Leicestershire

University Hospitals of Leicester NHS T…

Concerns summary Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.

Ian Reid

All Responded

2014-0288 30 Jun 2014 Cumbria (North & West)

Department of Health and Social Care

Jessica Bond

Historic (No Identified Response)

2014-0297 30 Jun 2014 Essex

Southend University Hospital

Concerns summary Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.

Ahmad Khan

Partially Responded

2014-0291 28 Jun 2014 South Yorkshire (West)

Sheffield County Council Q-Park Limited

Concerns summary Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.

Ashley Ponsonby

All Responded

2014-0386 27 Jun 2014 Manchester City

Concerns summary Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.

Sadik Miah

Historic (No Identified Response)

2014-0290 26 Jun 2014 London (Inner South)

South London and Maudsley NHS Trust

Concerns summary Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.

Marion Turner

Historic (No Identified Response)

2014-0300 25 Jun 2014 Essex

North Essex Partnership NHS Foundation …

Concerns summary A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.

Lloyd Butler

All Responded

2014-0281 25 Jun 2014 Birmingham & Solihull

West Midlands Police

Concerns summary A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.

Ralph Goslin

All Responded

2014-0282 25 Jun 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.

Wilfred Aspinwall

Historic (No Identified Response)

2014-0283 25 Jun 2014 Liverpool

Prison and Probation Ombudsman

Concerns summary Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.

Peter Hinchliffe

Historic (No Identified Response)

2014-0284 25 Jun 2014 South Yorkshire (East)

NHS England Sheffield Teaching Hospitals NHS Founda… BMI Hospital Thornbury +1 more

Concerns summary Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.

Joan Richardson

Partially Responded

2014-0276 23 Jun 2014 West Yorkshire (East)

Leeds West Clinical Commissioning Group Fountain Medical Centre

Concerns summary The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.