UK Inquiry Tracker

Gary Richards

All Responded

2014-0212 9 May 2014 London (Inner South)

South London and Maudsley Trust

Concerns summary Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.

Lisa Webb

Partially Responded

2014-0213 9 May 2014 London (Inner South)

Basildon Road Surgery NHS England

Concerns summary Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.

Ernest Harper

All Responded

2014-0223 9 May 2014 Bedfordshire & Luton

Bedford Borough Council

Concerns summary Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.

Frank Pope

Partially Responded

2014-0216 8 May 2014 London Inner (North)

Whittington Hospital NHS Trust Northern Medical Centre

Concerns summary There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.

Sopefoluwa Peters

All Responded

2014-0206 8 May 2014 County Durham & Darlington

Durham County Council

Concerns summary Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.

Rajesh Parkash

Historic (No Identified Response)

2014-0207 8 May 2014 Surrey

London Ambulance Service Association of Ambulance Chief Executiv…

Concerns summary Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.

Anthony Lapping

All Responded

2014-0214 8 May 2014 Newcastle Upon Tyne

Indesit Company

Concerns summary Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.

Emma Lifsey

Historic (No Identified Response)

2014-0204 7 May 2014 Nottinghamshire

Network Rail

Concerns summary Outdated, dim level crossing lights, inadequate research into sun glare, and a dangerously slow pace of upgrading equipment pose a significant ongoing risk to safety.

Peter Brookes

All Responded

2014-0205 7 May 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.

Donald Spooner

Partially Responded

2014-0208 5 May 2014 West Sussex

Royal Society for the Prevention of Acc… Department for Transport

Concerns summary The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.

Sidney Martin

All Responded

2014-0196 1 May 2014 North Yorkshire (West)

North West Waterways Canal & River Trust

Concerns summary The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.

Elizabeth Cooper

Historic (No Identified Response)

2014-0197 1 May 2014 Cumbria (South & East)

National Institute for Health and Care … General Medical Council

Concerns summary No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.

Darren Arnoup

Partially Responded

2014-0199 1 May 2014 Norfolk

NHS North Norfolk Clinical Commissionin… Mundesley Medical Centre

Concerns summary Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.

Sukbir Singh Rana & Mandip Singh

Historic (No Identified Response)

2014-0191 30 Apr 2014 Black Country

Sandwell Metropolitan Borough Council

Concerns summary The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical safe speed for the bend is also 60 MPH.

Mary Wanya

Historic (No Identified Response)

2014-0192 30 Apr 2014 West Yorkshire (East)

Leeds Teaching Hospitals NHS Trust

Concerns summary Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.

Beryl French

All Responded

2014-0198 30 Apr 2014 Nottinghamshire

Lifestyle Care PLC

Concerns summary Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.

Samiyo Farah

Partially Responded

2014-0202 30 Apr 2014 Manchester (North)

Royal College of Psychiatrists Affinity Healthcare Ltd Manchester Mental Health and Social Car… +3 more

Concerns summary Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.

Janet Blackman

Historic (No Identified Response)

2014-0200 29 Apr 2014 West Sussex

Department of Health and Social Care Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust

Concerns summary Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.

Joanne Oliver

Historic (No Identified Response)

2014-0210 29 Apr 2014 Manchester City

Intensive Care Society

Concerns summary A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.

Stephen Widman

Historic (No Identified Response)

2014-0189 29 Apr 2014 Plymouth, Torbay & South Devon

Department of Health and Social Care Torbay Hospital

Concerns summary The provided text does not detail any specific concerns.

Dafydd Watts

Historic (No Identified Response)

2014-0194 29 Apr 2014 Avon

UCB Pharma British National Formulary

Concerns summary Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.

Jennifer Tompkins

Historic (No Identified Response)

2014-0188 28 Apr 2014 London (Inner South)

Kings College Hospital NHS Foundation T…

Concerns summary Inadequate staff training on IV medication administration speed and a systemic failure to document early cessation of IV infusions pose a risk to patient safety.

Yasmin Richards

All Responded

2014-0193 28 Apr 2014 Avon

Highways Agency

Concerns summary The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.

Robert Perkins

All Responded

2014-0195 28 Apr 2014 Avon

North Bristol NHS Trust

Concerns summary A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, and insufficient staff awareness created a high risk of serious injury.

Stephen Goodhall

Historic (No Identified Response)

2014-0184 24 Apr 2014 Manchester (South)

University Hospital of South Manchester…

Concerns summary A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.