UK Inquiry Tracker

Anthony Huggan

All Responded

2014-0517 26 Nov 2014 Manchester (North)

Bury Metropolitan Borough Council

Concerns summary The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.

Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer

All Responded

2014-0520 25 Nov 2014 London Inner (North)

NHS England

Concerns summary Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.

Michael Harman

All Responded

2014-0514 25 Nov 2014 Norfolk

Centra Support

Concerns summary Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.

Stephen Mayoll

All Responded

2014-0515 25 Nov 2014 Portsmouth & South East Hampshire

Portsmouth Hospitals NHS Trust

Concerns summary The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.

Harold Penny

All Responded

2014-0507 24 Nov 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.

William Jackson

All Responded

2014-0509 24 Nov 2014 Cumbria (North & West)

Newcastle Foundation NHS Trust

Concerns summary The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.

William Hafele

All Responded

2014-0511 24 Nov 2014 Surrey

Surrey and Borders Partnership NHS Foun… Surrey Police

Concerns summary Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate Mr. Hafele's whereabouts.

Gaenor Moore

All Responded

2014-0512 24 Nov 2014 Surrey

Invacare Rehabilitation Dolby Vivisol Salter Labs

Concerns summary Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training regarding equipment setup.

Tracey Bannister

All Responded

2014-0506 21 Nov 2014 Black Country

Walsall Healthcare NHS Trust

Concerns summary Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.

Leanne Gower

All Responded

2014-0567 19 Nov 2014 Northampton

Police Safer Roads Team

Concerns summary Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and informed highway maintenance decisions.

Elsie Mallalieu

All Responded

2014-0501 17 Nov 2014 Manchester (South)

Tameside NHS Foundation Trust

Concerns summary Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.

Peter Dorney

All Responded

2014-0504 17 Nov 2014 Avon

Southmead Hospital

Concerns summary Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.

Dolores Hubbert

All Responded

2014-0500 14 Nov 2014 Sunderland

Sunderland City Council

Concerns summary Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could obscure driver visibility.

Kirk Williams

All Responded

2014-0499 14 Nov 2014 Teesside

IPCC

Concerns summary A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.

Marcus Szigetvari

All Responded

2014-0503 14 Nov 2014 Powys, Bridgend & Glamorgan Valleys

Rhondda Cyon Taff Highways Department

Concerns summary The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, contributing to a history of multiple collisions and fatalities.

Rowena Golton

All Responded

2014-0486 11 Nov 2014 Manchester (South)

Manchester Clinical Commissioning Group

Concerns summary Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.

William Davies

All Responded

2014-0475 5 Nov 2014 London Inner (North)

Care UK Limited

Concerns summary Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.

Santosh Muthiah

All Responded

2014-0476 5 Nov 2014 London (North)

Chief Fire Officers Association Trading Standards Institute Department for Business +9 more

Concerns summary The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.

Mark Hudson

All Responded

2014-0478 4 Nov 2014 Blackpool & Fylde

Blackpool Teaching Hospitals NHS Trust

Concerns summary Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.

Sandra Higham

All Responded

2014-0479 3 Nov 2014 London (Inner South)

Department of Health and Social Care

Concerns summary A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.

Christopher Ajayi

All Responded

2014-0558 31 Oct 2014 London (Inner South)

South London and Maudsley trust

Concerns summary A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.

Maureen Ellett

All Responded

2014-0473 31 Oct 2014 Brighton and Hove

Brighton and Sussex University Hospital… Royal Sussex County Hospital

Concerns summary Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.

Polly Carpenter

All Responded

2014-0469 28 Oct 2014 Exeter & Great Devon

Devon Partnership NHS Trust

Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

Philip Allen

All Responded

2014-0466 27 Oct 2014 London (Inner South)

Eltham Palace Surgery

Concerns summary The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.

Agnes Hannan

All Responded

2014-0573 27 Oct 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.