UK Inquiry Tracker

Michael Worrall

Historic (No Identified Response)

2014-0179 22 Apr 2014 London Inner (North)

Barnet Enfield and Haringey Mental Heal…

Concerns summary The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.

Andrey Wakefield

All Responded

2014-0186 22 Apr 2014 Staffordshire (South)

University Hospital of North Staffordsh…

Concerns summary Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.

Rosemary Oladejo

All Responded

2014-0203 22 Apr 2014 London (West)

NHS Hillingdon Clinical Commissioning G… Central and North West London NHS Found…

Concerns summary A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.

Muriel Dawson

Partially Responded

2014-0173 17 Apr 2014 West Yorkshire (West)

Vehicle Operator Services Agency Optare Transport Research Laboratory

Concerns summary The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately consider the risk of death or serious injury.

Paul Millis

All Responded

2014-0176 17 Apr 2014 Leicester City & South Leicestershire

Leicester City Council

Concerns summary The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.

Karen Peters

Historic (No Identified Response)

2014-0178 17 Apr 2014 Plymouth, Torbay & South Devon

Royal Cornwall Hospitals NHS Trust

Concerns summary No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.

Kathryn Sawyer

All Responded

2014-0177 16 Apr 2014 Norfolk

Roundwell Medical Centre

Concerns summary A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.

Sari Keen

All Responded

2014-0180 16 Apr 2014 Bedfordshire & Luton

Luton and Dunstable University Hospital

Concerns summary Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.

Desiree Falvo

All Responded

2014-0171 15 Apr 2014 London Inner (West)

NHS England

Concerns summary A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.

Philip Dean

Partially Responded

2014-0172 15 Apr 2014 London (Inner West)

South Wet London and St George’s Mental… Clinical Commissioning Group for Wandsw…

Concerns summary Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.

Kevin Scarlett

All Responded

2014-0174 15 Apr 2014 Milton Keynes

National Offender Management Service

Concerns summary The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.

Nicos Michael

All Responded

2014-0168 14 Apr 2014 Kent (North-East)

East Kent Hospitals University NHS Foun…

Concerns summary Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic failures in allergy documentation and communication.

Winifred Dennis

All Responded

2014-0167 14 Apr 2014 Kent (North-East)

Kent Community Health NHS Trust

Concerns summary Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.

Paul Ashton

Partially Responded

2014-0170 14 Apr 2014 Manchester (West)

Medicines and Healthcare Products Regul… Department of Health and Social Care

Concerns summary There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.

Francis Golding

All Responded

2014-0136 14 Apr 2014 London Inner (North)

Camden Council

Concerns summary The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised safety improvements.

Lalitaben Patel

All Responded

2014-0175 13 Apr 2014 Leicester City & South Leicestershire

Department of Health and Social Care

Concerns summary A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.

Terence Dooley

All Responded

2014-0162 10 Apr 2014 Manchester City

North West Ambulance Service

Concerns summary A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion of multiple potentially fatal tablets.

Michael Anthony

Partially Responded

2014-0161 9 Apr 2014 London (Inner South)

Princess Street Practice Guy’s Hospital

Concerns summary The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP for its prescription.

Doris Taylor

Historic (No Identified Response)

2014-0164 9 Apr 2014 Manchester (South)

Borough Care Limited

Concerns summary Staff training was inadequate regarding reportable incidents, and managers were unaware of reporting duties. Dangerously strong door-closers also posed a significant safety hazard to residents.

Ozan Atasoy

All Responded

2014-0166 9 Apr 2014 Hertfordshire

Care Quality Commission

Concerns summary A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.

Russell Long

All Responded

2014-0165 9 Apr 2014 Cumbria (North & West)

Cumbria County Council

Sally Perrons

All Responded

2014-0158 9 Apr 2014 Nottinghamshire

Association of Ambulance Chief Executiv… East Midlands Ambulance Service NHS Tru…

Concerns summary No specific concerns were detailed in the provided text for summarization.

Stephen Bedford

Historic (No Identified Response)

2014-0159 9 Apr 2014 Cambridgeshire (South & West)

East of England Ambulance NHS Trust

Concerns summary Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.

Thomas Allen

Partially Responded

2014-0160 9 Apr 2014 Suffolk

Department for Environment Suffolk Constabulary Food and Rural Affairs

Concerns summary The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary police/local authority protocol is not yet in force.

Andrew Horgan

All Responded

2014-0163 8 Apr 2014 Wiltshire & Swindon

Great Western Hospital

Concerns summary Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.