UK Inquiry Tracker

Mr Pether

Historic (No Identified Response)

2014-0432 2 Oct 2014 London (East)

Barking, Havering and Redbridge Univers…

Concerns summary Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.

Gavin Bradley, Mark Thorpe and Darren Thorpe

Historic (No Identified Response)

2014-0424 2 Oct 2014 Northumberland (South)

Northumbria Water

Concerns summary Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.

Derek Hawkins

Historic (No Identified Response)

2014-0425 30 Sep 2014 Manchester (North)

Not Listed

Concerns summary The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.

Victoria Rhodes

All Responded

2014-0422 30 Sep 2014 Milton Keynes

Milton Keynes Council

Concerns summary High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.

Tiya Chauhan

All Responded

2014-0575 29 Sep 2014 London Inner (West)

Department for Education Ofsted Food Standards Agency

Concerns summary Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking adequate warnings and supervision during play being insufficient.

Christopher Davies

Historic (No Identified Response)

2014-0420 29 Sep 2014 North Wales (East & Central)

Betsi Cadwaladr University Health Boar

Concerns summary Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.

Dorothy Clarkson

Historic (No Identified Response)

2014-0465 26 Sep 2014 Preston & West Lancashire

MPS Investments Ltd Care Quality Commission

Concerns summary Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.

Emmanuel Akinmuyiwa

Historic (No Identified Response)

2014-0421 26 Sep 2014 Birmingham & Solihull

NHS England Birmingham and Solihull Clinical Commis…

Concerns summary The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.

Isa Mushtaq

Historic (No Identified Response)

2014-0423 24 Sep 2014 Manchester (City)

Department of Health and Social Care National Institute for Health and Care … Royal College of Gynaecologists and Obs…

Concerns summary A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.

Jake Johnson

Historic (No Identified Response)

2014-0417 24 Sep 2014 Cheshire

Highways Agency

Concerns summary Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack of warning signs, especially near a children's play area.

Caroline Carter Crowther

Historic (No Identified Response)

2014-0418 24 Sep 2014 Worcestershire

West Midlands Ambulance Trust

Concerns summary Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.

Leonard Hudson

Historic (No Identified Response)

2014-0419 24 Sep 2014 Sunderland

City Hospitals Sunderland NHS Foundatio…

Concerns summary Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.

Jerome Gonnet

Partially Responded

2014-0415 22 Sep 2014 Teesside

Cleveland Police Roads Policing Unit A-One+

Concerns summary Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers entering incorrectly.

Martin Dean

Historic (No Identified Response)

2014-0416 22 Sep 2014 Manchester West

Salford Royal Foundation Trust

Concerns summary Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.

Aaron Plowman

Historic (No Identified Response)

2014-0411 19 Sep 2014 London (Inner South)

Network Rail

Concerns summary Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, posing a safety risk.

Satheeskumar Mahatheaven

All Responded

2014-0412 19 Sep 2014 London Inner (North)

HMP Pentonville

Concerns summary Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.

Linda Rignall

Historic (No Identified Response)

2014-0414 19 Sep 2014 Brighton & Hove

Royal Sussex County Hospital

Concerns summary A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.

Janet Goodacre

All Responded

2014-0408 18 Sep 2014 Leicester City & South Leicestershire

University Hospitals of Leicester NHS T…

Concerns summary The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.

William France

Historic (No Identified Response)

2014-0409 18 Sep 2014 Somerset (West)

Network Rail

Concerns summary Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and a poorly located emergency telephone.

Brian Dalrymple

Partially Responded

2014-0410 18 Sep 2014 West London

Practice Plc Nestor Primecare Serco +2 more

Concerns summary Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained medical staff, deficient medical assessments, and lack of comprehensive clinical records.

Marjorie Phillips

All Responded

2014-0413 18 Sep 2014 Manchester (South)

Sunrise Medical Limited

Concerns summary The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.

Beatrice Gatt

Historic (No Identified Response)

2014-0566 18 Sep 2014 Northampton

Shire Lodge Nursing Home

Concerns summary A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.

George Palmer

All Responded

2014-0407 15 Sep 2014 Surrey

Community Mental Health Recovery Servic…

Concerns summary Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.

Sybil Roberts

Historic (No Identified Response)

2014-0402 12 Sep 2014 North Wales (East & Central)

Manor Park Residential Home

Concerns summary A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.

Ian Page

Historic (No Identified Response)

2014-0403 12 Sep 2014 Carmarthenshire & Pembrokeshire

Withybush General Hospital

Concerns summary Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.