UK Inquiry Tracker

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.

Martin McCabe

Historic (No Identified Response)

2014-0505 20 Nov 2014 Powys, Bridgend & Glamorgan Valleys

Cwm Taf Health Board

Concerns summary The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.

George Werb

Partially Responded

2014-0510 19 Nov 2014 Exeter & Greater Devon

NHS England Devon Clinical Commissioning Group

Concerns summary The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate communication.

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.

Gladys Smith

Historic (No Identified Response)

2014-0502 17 Nov 2014 West Yorkshire (East)

St Armands Court Residential Care Home Moorfield House Surgery Leeds Community Healthcare NHS Trust +1 more

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

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.

John Wright

Historic (No Identified Response)

2014-0494 13 Nov 2014 Nottinghamshire

Network Rail Rail Maritime and Transport Union Rail Accident Investigation Branch +1 more

Concerns summary Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. There was also a concern about balancing hearing protection with the ability to hear oncoming trains.

Patricia Mellor

Historic (No Identified Response)

2014-0491 12 Nov 2014 Nottinghamshire

Medicines and Healthcare Product Regula… National Institute for Health and Care … National Patient Safety Agency +1 more

Concerns summary Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.

Lorraine Sheridan

Historic (No Identified Response)

2014-0496 12 Nov 2014 Black Country

Sandwell Metropolitan Borough Council

Concerns summary Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.

David Ince

Historic (No Identified Response)

2014-0497 12 Nov 2014 Preston & West Lancashire

North West Ambulance Service NHS Trust

Concerns summary Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.

Neophytos Constantinou

Historic (No Identified Response)

2014-0498 12 Nov 2014 London Inner (North)

Chalfont Road Surgery Royal Free London NHS Foundation Trust

Concerns summary Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.

Beryl Walters

Historic (No Identified Response)

2014-0489 11 Nov 2014 Black Country

National Institute for Clinical Excelle… College of Emergency Medicine

Concerns summary Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.

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.

Mary Hallworth

Historic (No Identified Response)

2014-0487 11 Nov 2014 Manchester (South)

Home Instead Senior Care

Concerns summary A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.

Amar Majid

Historic (No Identified Response)

2014-0495 11 Nov 2014 Coventry

Coventry City Council

Concerns summary Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.

Myra Goldman

Partially Responded

2014-0490 10 Nov 2014 Manchester (North)

Health and Safety Executive British Standards Institute Spaces and Places Limited

Concerns summary Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being easily removed and ensure even load distribution.

Roseanne Cooke

All Responded

2014-0485 10 Nov 2014 Manchester (South)

Concerns summary Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.

Mark Hancock

Historic (No Identified Response)

2014-0484 10 Nov 2014 Manchester (South)

Priory Group

Concerns summary Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for managing patients requiring admission when beds are unavailable.

Barry Horrocks

Historic (No Identified Response)

2014-0492 7 Nov 2014 West Yorkshire (East)

National Offender Management Service NHS England

Concerns summary A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.