UK Inquiry Tracker

Sophie Allen

All Responded

2014-0256 5 Jun 2014 Sunderland

Department for Business Innovation and …

Concerns summary Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new standards.

Archie Hames

Partially Responded

2014-0259 5 Jun 2014 Surrey

Department of Health and Social Care Surrey Community Health

Concerns summary The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with similar devices.

Thomas Maher

All Responded

2014-0252 5 Jun 2014 Manchester (South)

Central Manchester University Hospitals…

Concerns summary Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.

John Day

All Responded

2014-0251 4 Jun 2014 Isle of Wight

Beacon Healthcare Isle of Wight Clinical Commissioning Gr…

Concerns summary Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.

Robert Wood

All Responded

2014-0556 3 Jun 2014 Wiltshire and Swindon

Concerns summary Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.

Dean Hutchinson

All Responded

2014-0556-wp26759 3 Jun 2014 Wiltshire and Swindon

Ministry of Defence

Denise Prior

All Responded

2014-0262 2 Jun 2014 West Sussex

Western Sussex Hospitals NHS Trust

Concerns summary Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.

Jennifer Morrison

All Responded

2014-0265 2 Jun 2014 Wirral

Arrowe Park Hospital

Concerns summary Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.

Aimee Varney

All Responded

2014-0249 2 Jun 2014 Bedfordshire & Luton

Luton and Dunstable University Hospital

Concerns summary NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.

Essa Shah

All Responded

2014-0250 2 Jun 2014 Bedfordshire & Luton

Luton and Dunstable University Hospital

Concerns summary Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.

Richard Jaeger-Forzard

All Responded

2014-0246 30 May 2014 Buckinghamshire

Terex Global Gmbh

Concerns summary The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.

Matthew Purser

Historic (No Identified Response)

2014-0568 30 May 2014 Swansea & Neath Port Talbot

HMP Swansea National Offender Management Service

Concerns summary A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.

Dana Baker

All Responded

2014-0242 29 May 2014 Worcestershire

Worcestershire Safeguarding Children’s …

Concerns summary Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.

Loui Aspinall

Historic (No Identified Response)

2014-0243 29 May 2014 Manchester (West)

Federation of British Tour Operators

Concerns summary Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap between audit findings and actual safety provisions.

Magdalen Dwerryhouse

All Responded

2014-0244 29 May 2014 Manchester (West)

5 Boroughs Partnership NHS Foundation T…

Concerns summary Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.

Mark Duggan

All Responded

2014-0182 29 May 2014 London (North)

Independent Police Complaints Commission Metropolitan Police National Crime Agency +2 more

Concerns summary Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.

Stephen Ward

All Responded

2014-0248 29 May 2014 London Inner (North)

Camden & Islington NHS Foundation Trust

Concerns summary The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.

Laura Page

All Responded

2014-0254 28 May 2014 Leicester City & South Leicestershire

Leicester Partnership NHS Trust

Concerns summary Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.

Arnold Soulsby

All Responded

2014-0241 28 May 2014 Black Country

Department for Transport

Concerns summary Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.

Gerardo Tonogbanua

Historic (No Identified Response)

2014-0245 27 May 2014 Avon

Department for Transport British Standards Institution Maritime and Coastguard Agency

Concerns summary A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also failed, exacerbated by vague guidance on safety device performance.

Liam Coleman

Historic (No Identified Response)

2014-0312 25 May 2014 London (North)

Department of Health and Social Care

Concerns summary There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.

Michaela Christoforou

All Responded

2014-0285 25 May 2014 London (North)

Care UK

Concerns summary All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Ross Boyd

All Responded

2014-0313 23 May 2014 Milton Keynes

REDACTED

Concerns summary An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.

Clive Clinton

Historic (No Identified Response)

2014-0238 23 May 2014 North Wales (East & Central)

European Care

Concerns summary A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.

Samarjit Singh

Partially Responded

2014-0239 23 May 2014 Wirral

Department of Health and Social Care NHS England Wirral Clinical Commissioning Group

Concerns summary The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.