UK Inquiry Tracker

Peter Farebrother

Historic (No Identified Response)

2014-0274 20 Jun 2014 Shropshire, Telford & Wrekin

South Stafford and Shropshire Healthcar…

Concerns summary Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.

Else Harvey-Samuel

Historic (No Identified Response)

2014-0278 20 Jun 2014 Suffolk

West Suffolk Hospital

Concerns summary Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.

Redmond Johnson

Historic (No Identified Response)

2014-0279 20 Jun 2014 Suffolk

NHS England Ministry of Justice

Concerns summary Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.

Samuel Openshaw

Historic (No Identified Response)

2014-0280 20 Jun 2014 Suffolk

East Anglia Team Coronary Heart Disease Review Congenital Heart Services Clinical Refe… +1 more

Concerns summary Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.

M5 (Seven)

Historic (No Identified Response)

2014-0654 19 Jun 2014 Somerset (West)

Directorate for Business Innovation and… Health and Safety Executive Department for Transport

Concerns summary A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a lack of preventative measures for such events.

Shaun Maslin

Partially Responded

2014-0277 19 Jun 2014 Surrey

Department of Business Innovations and Skills Energy and Utilities Skills

Concerns summary There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular retraining and re-testing of gas industry operatives.

Audrey Garland

Partially Responded

2014-0271 17 Jun 2014 Manchester (South)

Blackpool Teaching Hospitals NHS Founda… North Shore Surgery

Concerns summary Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.

Sol Hadhasseh

Historic (No Identified Response)

2014-0272 17 Jun 2014 Norfolk

Coventry and Warwickshire Partnership N…

Concerns summary A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.

David O’Garro

Historic (No Identified Response)

2014-0270 16 Jun 2014 London Inner (North)

HMP Pentonville

Concerns summary A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, created an unsafe cell allocation system.

Mrs Care

Historic (No Identified Response)

2014-0273 16 Jun 2014 Cornwall

Royal Cornwall Hospital Truro

Concerns summary Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.

Alun Sheppard

All Responded

2014-0268 13 Jun 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Bridget Cahill

All Responded

2014-0266 11 Jun 2014 Black Country

National Institute for Health and Clini…

Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.

June Rose

Historic (No Identified Response)

2014-0267 11 Jun 2014 London (West)

Royal College of General Practitioners

Concerns summary A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.

Lucy Moffatt

All Responded

2014-0261 10 Jun 2014 South Yorkshire (West)

Care Quality Commission Department of Health and Social Care

Concerns summary Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.

Ryan Boyle

All Responded

2014-0263 9 Jun 2014 Surrey

Surrey Police

Concerns summary Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.

Charles Hardiman

Historic (No Identified Response)

2014-0257 9 Jun 2014 Teesside

Stockton Public House

Concerns summary An open front door created a wind tunnel, causing the back door of a public house to move forcibly and suddenly, leading to an accident.

William Beckwith

All Responded

2014-0258 9 Jun 2014 Derby & Derbyshire

Chesterfield Royal Hospital

Concerns summary A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

Daniel McCallum Keane

All Responded

2014-0260 9 Jun 2014 Manchester (West)

Department of Health and Social Care

Concerns summary The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.

Bradley Cockel

Unknown

2014-0298 9 Jun 2014 Essex

Concerns summary The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public health risks.

John Cook

All Responded

2014-0578 9 Jun 2014 Oxfordshire

NHS England

Concerns summary Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.

Audrey Daws

Historic (No Identified Response)

2014-0318 9 Jun 2014 Plymouth, Torbay & South Devon

Plymouth Hospitals NHS Trust

Concerns summary Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.

James McArdle

All Responded

2014-0264 8 Jun 2014 Wirral

Arrow Park Hospital NHS Trust

Concerns summary The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.

James Boylan

Partially Responded

2014-0253 6 Jun 2014 Cumbria (South & East)

Cumbria Partnerships NHS Foundation Tru… Cumbria Clinical Commissioning Group Care Quality Commission +2 more

Concerns summary Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.

Katie Davies

All Responded

2014-0255 6 Jun 2014 Manchester (West)

Department of Health and Social Care

Concerns summary Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.

Frances Bell

Historic (No Identified Response)

2014-0299 6 Jun 2014 Essex

Southend Hospital

Concerns summary The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.