UK Inquiry Tracker

Phyllis Barnes

Historic (No Identified Response)

2014-0138 24 Mar 2014 Surrey

North East Hampshire and Farnham Clinic… Royal College of Surgeons Frimley Park Hospital NHS Trust

Concerns summary A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.

Sean Morley

Historic (No Identified Response)

2014-0132 24 Mar 2014 Warwickshire

Warwickshire County Council

Concerns summary The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.

Norma Sheppard

Historic (No Identified Response)

2014-0129 21 Mar 2014 Staffordshire South

Queens Hospital Burton Upon Trent

Concerns summary Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.

Christopher Williams

Historic (No Identified Response)

2014-0131 19 Mar 2014 Cheshire

St Mary’s Hospital Warrington

Concerns summary A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.

Daniel Taylor

Historic (No Identified Response)

2014-0125 17 Mar 2014 Staffordshire (South)

Casualty Reduction Team

Concerns summary A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review to prevent future collisions.

Peter Banks

Historic (No Identified Response)

2014-0124 17 Mar 2014 Staffordshire South

Casualty Reduction Team

Concerns summary A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and the crossing moved further into Westhead Avenue to improve safety.

Charles Bradley

Historic (No Identified Response)

2014-0118 17 Mar 2014 Liverpool

Arrowe Park Hospital

Concerns summary Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.

Matthew Simmonds

Historic (No Identified Response)

2014-0119 14 Mar 2014 Hampshire (Central)

NHS England

Concerns summary An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.

Gavin Roberts

Historic (No Identified Response)

2014-0120 14 Mar 2014 Rotherham

Rotherham Metropolitan Borough Council

Concerns summary The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases on approach, contributing to repeated incidents.

Noel Williams

Historic (No Identified Response)

2014-0123 13 Mar 2014 Teesside

South Tees NHS Trust

Concerns summary A critical failure occurred in communicating recent haemoglobin test results to the surgical team. This information was vital for assessing surgical fitness and could have altered treatment or delayed surgery.

Stephen Tilbury

Historic (No Identified Response)

2014-0109 12 Mar 2014 London (East)

London Borough of Havering

Concerns summary Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding vehicles onto the pavement. Physical speed reduction measures are needed.

Christopher Shapley

Historic (No Identified Response)

2014-0121 11 Mar 2014 Cardiff & the Vale of Glamorgan

HM Prison Cardiff Home Office

Concerns summary Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.

Lorna Cullen

Historic (No Identified Response)

2014-0105 11 Mar 2014 Mid Kent & Medway

NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group

Concerns summary Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for mental health assessments, hindering timely risk identification and management for vulnerable patients.

Afifa Qaisar

Historic (No Identified Response)

2014-0107 11 Mar 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.

Teresa Lonergan

Historic (No Identified Response)

2014-0110 11 Mar 2014 London (Inner South)

Eltham Park Surgery

Concerns summary The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.

Derrick Rivers

Historic (No Identified Response)

2014-0104 10 Mar 2014 Manchester (North)

Rochdale Metropolitan Borough Council Care Quality Commission Passmonds Care Home

Concerns summary The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.

John Fox

Historic (No Identified Response)

2014-0098 5 Mar 2014 : London Inner (West)

St George’s Hospital

Concerns summary Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.

Barry Dillion

Historic (No Identified Response)

2014-0099 5 Mar 2014 Blackburn, Hyndburn & Ribble Valley

East Lancashire Healthcare NHS Trust

Concerns summary Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.

Nellie Travis

Historic (No Identified Response)

2014-0101 5 Mar 2014 Manchester (South)

Tameside Hospital NHS Foundation Trust

Concerns summary The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.

Stephen Ellis

Historic (No Identified Response)

2014-0102 5 Mar 2014 Manchester (South)

Department of Health and Social Care

Concerns summary A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.

Anne-Marie Katherine Ellement

Historic (No Identified Response)

2014-0181 4 Mar 2014 Wiltshire & Swindon

Provost Marshall (Army)

Concerns summary The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.

Ryan Pettengell

Historic (No Identified Response)

2014-0096 4 Mar 2014 Norfolk

Sibelco UK Ltd Borough Council of King’s Lynn & West N… Norfolk Police +1 more

Concerns summary Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.

Kevin Pearson

Historic (No Identified Response)

2014-0086 3 Mar 2014 North Lincolnshire & Grimsby

John Somerscales Ltd

Concerns summary The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.

Kirabo Kiwanuka

Historic (No Identified Response)

2014-0088 3 Mar 2014 London (Inner South)

Royal College of Psychiatrists Royal College of Physicians

Concerns summary Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.

Margaret Easterfield

Historic (No Identified Response)

2014-0091 3 Mar 2014 Kent (South East & Central)

East Kent University Hospital

Concerns summary A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.