UK Inquiry Tracker

Elaine Jobe

All Responded

2014-0350 14 Jul 2014 Exeter & Great Devon

Devon Partnership NHS Trust

Concerns summary Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.

Adam Williams

All Responded

2014-0324 14 Jul 2014 Staffordshire (South)

HMP Featherstone

Concerns summary Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential for further CCTV installation.

David Giles

All Responded

2014-0321 9 Jul 2014 Birmingham & Solihull

Home Office

Concerns summary The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, contributes to a concerning rise in helium-related suicides.

Anthony Ponting

All Responded

2014-0332 8 Jul 2014 Somerset (West)

Network Rail

Harold de Mello

All Responded

2014-0449 7 Jul 2014 London Inner (North)

Tower Hamlets Social Services

Concerns summary A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.

Helena Farrell

All Responded

2014-0309 3 Jul 2014 Cumbria (South & East)

Cumbria Partnership NHS Foundation Trust Cumbria County Council

Concerns summary Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified qualifications and professional oversight.

Beryl Brinkman

All Responded

2014-0314 2 Jul 2014 Manchester (North)

Rochdale Metropolitan Borough Council

Concerns summary Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.

Henry Marsh

All Responded

2014-0306 2 Jul 2014 London (North)

Department of Health and Social Care

Concerns summary The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.

Ronald Perry

All Responded

2014-0302 2 Jul 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.

Albert Flynn

All Responded

2014-0308 2 Jul 2014 Manchester (South)

HC-One

Concerns summary Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.

Gary Daltry

All Responded

2014-0295 2 Jul 2014 North Wales (East & Central)

Denbighshire County Council

Concerns summary An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.

Sindy Woodhall

All Responded

2014-0292 1 Jul 2014 Manchester (North)

Trading Standards Institute Oldham Metropolitan Borough Council Department for Business Innovation and … +1 more

Concerns summary A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that poses a health risk.

Dayani Chauhan-Ahmed

All Responded

2014-0287 30 Jun 2014 Leicester City & South Leicestershire

University Hospitals of Leicester NHS T…

Concerns summary Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.

Ian Reid

All Responded

2014-0288 30 Jun 2014 Cumbria (North & West)

Department of Health and Social Care

Lloyd Butler

All Responded

2014-0281 25 Jun 2014 Birmingham & Solihull

West Midlands Police

Concerns summary A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.

Ralph Goslin

All Responded

2014-0282 25 Jun 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.

Alun Sheppard

All Responded

2014-0268 13 Jun 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Bridget Cahill

All Responded

2014-0266 11 Jun 2014 Black Country

National Institute for Health and Clini…

Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.

Lucy Moffatt

All Responded

2014-0261 10 Jun 2014 South Yorkshire (West)

Care Quality Commission Department of Health and Social Care

Concerns summary Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.

Ryan Boyle

All Responded

2014-0263 9 Jun 2014 Surrey

Surrey Police

Concerns summary Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.

William Beckwith

All Responded

2014-0258 9 Jun 2014 Derby & Derbyshire

Chesterfield Royal Hospital

Concerns summary A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

Daniel McCallum Keane

All Responded

2014-0260 9 Jun 2014 Manchester (West)

Department of Health and Social Care

Concerns summary The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.

John Cook

All Responded

2014-0578 9 Jun 2014 Oxfordshire

NHS England

Concerns summary Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.

James McArdle

All Responded

2014-0264 8 Jun 2014 Wirral

Arrow Park Hospital NHS Trust

Concerns summary The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.

Katie Davies

All Responded

2014-0255 6 Jun 2014 Manchester (West)

Department of Health and Social Care

Concerns summary Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed appropriate care.