UK Inquiry Tracker

Colin Ireland

Historic (No Identified Response)

2014-0493 7 Nov 2014 West Yorkshire (West)

HMP Manchester

Concerns summary Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.

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)

Association of Manufacturers Of Domesti… Department of Communities and Local Gov… Chief Fire Officers Association +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.

Rebecca Curtis-Small

Partially Responded

2014-0483 4 Nov 2014 Exeter & Greater Devon

Parkdeane Holidays Royal National Lifeboat Institute Maritime and Coastguard Agency +1 more

Concerns summary Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.

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

Royal Sussex County Hospital Brighton and Sussex University 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.

Alan Evans

Historic (No Identified Response)

2014-0472 29 Oct 2014 Powys, Bridgend & Glamorgan Valleys

Powys Highways Department

Concerns summary The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk requiring double white lines and slim-line catseye replacement.

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.

Betty Smith

Historic (No Identified Response)

2014-0467 27 Oct 2014 Kent (South East & Central)

East Kent Hospitals University NHS Foun…

Concerns summary Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.

Jackson Mitchell

Partially Responded

2014-0468 27 Oct 2014 Norfolk

Queen Elizabeth Hospital King’s Lynn NH… Norfolk and Norwich University Hospital… NHS England

Concerns summary The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.

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.

Cherylin Norrell-Goldsmith

Partially Responded

2014-0470 27 Oct 2014 Surrey

Surrey and Borders Partnership NHS Foun… HMP Downview Virgin Care

Concerns summary Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.

Hilda Cole

Historic (No Identified Response)

2014-0460 24 Oct 2014 Staffordshire (South)

Care Quality Commission

Concerns summary The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.

Eliza Bashir

Partially Responded

2014-0461 24 Oct 2014 Manchester (North)

Oldham Metropolitan Borough Council Department of Health and Social Care Central Manchester University Hospitals…

Concerns summary Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.

Phyllis Kerry

All Responded

2014-0457 23 Oct 2014 Nottinghamshire

Nottingham University Hospitals NHS Tru…

Concerns summary There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.

Sonielia Holmes

Historic (No Identified Response)

2014-0459 23 Oct 2014 Bedfordshire & Luton

Bedford Hospital NHS Trust

Concerns summary Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient lives at risk due to lack of specialist advice.

Maria Stubbings

Historic (No Identified Response)

2014-0458 23 Oct 2014 Essex

Treasury Solicitors Home Office Ministry of Justice

Concerns summary Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.

Mary Stroman

All Responded

2014-0454 21 Oct 2014 Wiltshire & Swindon

Haringey Council

Concerns summary A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory accommodation thresholds.

Elsie Plumb

Historic (No Identified Response)

2014-0455 21 Oct 2014 Avon

Royal College of Obstetricians and Gyna…

Concerns summary The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.

Samuel Duckworth

All Responded

2014-0456 20 Oct 2014 London (Inner South)

Department of Health and Social Care

Concerns summary The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.

Stephen Atherton

Historic (No Identified Response)

2014-0451 17 Oct 2014 London Inner (North)

Tredegar Practice

Concerns summary The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.

William Anderson

Historic (No Identified Response)

2014-0452 17 Oct 2014 West Yorkshire (East)

National Offender Management Service Leeds Community Healthcare NHS Trust

Concerns summary Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.