UK Inquiry Tracker

Amanda Richards

All Responded

2014-0228 12 May 2014 Coventry

Whitefriars Housing

Concerns summary The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.

Abiola Dosunmu

All Responded

2014-0209 9 May 2014 London (Inner South)

Kings College Hospital NHS Foundation T…

Concerns summary Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.

Margaret Connor

All Responded

2014-0215 9 May 2014 Norfolk

Heathers Nursing Home

Concerns summary Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.

Gianna Khan

All Responded

2014-0219 9 May 2014 Bedfordshire & Luton

Bedfordshire Clinical Commissioning Gro…

Concerns summary A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, indicating a critical failure in triage protocols, which was impeded by the CCG.

Linda Fisher

All Responded

2014-0226 9 May 2014 Blackpool & Fylde

Blackpool Teaching Hospitals NHS Founda…

Concerns summary Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.

Akua Anokye-Boateng

All Responded

2014-0211 9 May 2014 London (Inner South)

Medicines and Healthcare Products Regul…

Concerns summary There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell disease, particularly concerning routine GI protection.

Gary Richards

All Responded

2014-0212 9 May 2014 London (Inner South)

South London and Maudsley Trust

Concerns summary Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.

Ernest Harper

All Responded

2014-0223 9 May 2014 Bedfordshire & Luton

Bedford Borough Council

Concerns summary Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.

Sopefoluwa Peters

All Responded

2014-0206 8 May 2014 County Durham & Darlington

Durham County Council

Concerns summary Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.

Anthony Lapping

All Responded

2014-0214 8 May 2014 Newcastle Upon Tyne

Indesit Company

Concerns summary Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.

Peter Brookes

All Responded

2014-0205 7 May 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.

Sidney Martin

All Responded

2014-0196 1 May 2014 North Yorkshire (West)

North West Waterways Canal & River Trust

Concerns summary The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.

Beryl French

All Responded

2014-0198 30 Apr 2014 Nottinghamshire

Lifestyle Care PLC

Concerns summary Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.

Yasmin Richards

All Responded

2014-0193 28 Apr 2014 Avon

Highways Agency

Concerns summary The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.

Robert Perkins

All Responded

2014-0195 28 Apr 2014 Avon

North Bristol NHS Trust

Concerns summary A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, and insufficient staff awareness created a high risk of serious injury.

Andrey Wakefield

All Responded

2014-0186 22 Apr 2014 Staffordshire (South)

University Hospital of North Staffordsh…

Concerns summary Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.

Rosemary Oladejo

All Responded

2014-0203 22 Apr 2014 London (West)

NHS Hillingdon Clinical Commissioning G… Central and North West London NHS Found…

Concerns summary A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.

Paul Millis

All Responded

2014-0176 17 Apr 2014 Leicester City & South Leicestershire

Leicester City Council

Concerns summary The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.

Kathryn Sawyer

All Responded

2014-0177 16 Apr 2014 Norfolk

Roundwell Medical Centre

Concerns summary A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.

Sari Keen

All Responded

2014-0180 16 Apr 2014 Bedfordshire & Luton

Luton and Dunstable University Hospital

Concerns summary Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.

Desiree Falvo

All Responded

2014-0171 15 Apr 2014 London Inner (West)

NHS England

Concerns summary A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.

Kevin Scarlett

All Responded

2014-0174 15 Apr 2014 Milton Keynes

National Offender Management Service

Concerns summary The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.

Nicos Michael

All Responded

2014-0168 14 Apr 2014 Kent (North-East)

East Kent Hospitals University NHS Foun…

Concerns summary Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic failures in allergy documentation and communication.

Winifred Dennis

All Responded

2014-0167 14 Apr 2014 Kent (North-East)

Kent Community Health NHS Trust

Concerns summary Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.

Francis Golding

All Responded

2014-0136 14 Apr 2014 London Inner (North)

Camden Council

Concerns summary The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised safety improvements.