UK Inquiry Tracker

Craig Marren

All Responded

2014-0106 10 Mar 2014 West Yorkshire (East)

Tyersal Farm

Concerns summary Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.

Neil Carter

All Responded

2014-0103 5 Mar 2014 London (West)

Care Quality Commission Priory Group

Concerns summary There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.

Kathleen Border

All Responded

2014-0095 4 Mar 2014 Portsmouth & South East Hampshire

Northwood Square

Concerns summary Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.

Carl Morris

All Responded

2014-0092 3 Mar 2014 Cumbria (North & West)

Professional Association of Diving Inst…

Marco Lima De Araujo

All Responded

2014-0093 3 Mar 2014 Portsmouth & South East Hampshire

Queen’s Harbour Master Portsmouth

Concerns summary There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.

Peter Norman Nott

All Responded

2014-0229 28 Feb 2014 Oxfordshire

Rush Court Nursing Home

Concerns summary Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

Richard White

All Responded

2014-0085 28 Feb 2014 County Durham & Darlington

700 Club

Concerns summary Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.

Samuel Shaw

All Responded

2014-0076 26 Feb 2014 North Northumberland

Highways Agency

Concerns summary Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and no central refuge.

Arthur Brockett-Deakins

All Responded

2014-0077 25 Feb 2014 London (Inner South)

National Institute for Clinical Excelle… Department of Health and Social Care Medicines and Health Regulatory Authori… +1 more

Concerns summary Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.

Andre Matei

All Responded

2014-0089 25 Feb 2014 London (North)

Department of Health and Social Care

Concerns summary There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities in operating theatres.

Kenneth Aldridge

All Responded

2014-0071 24 Feb 2014 Berkshire

West Berkshire Highways Authority

Concerns summary The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway safety risk.

Benjamin James Carroll

All Responded

2014-0068 20 Feb 2014 Gwent

Welsh Cycling

Concerns summary The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.

Jack Lynn

All Responded

2014-0066 18 Feb 2014 North Northumberland

Nightingale Home Help Service

Concerns summary The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.

Laura Hill

All Responded

2014-0064 17 Feb 2014 Manchester (South)

Stepping Hill Hospital

Concerns summary Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

Refat Hussain

All Responded

2014-0061 12 Feb 2014 London Inner (West)

Harmoni HS

Concerns summary Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.

Adrian Cowan

All Responded

2014-0111 7 Feb 2014 London (North)

North London Forensic Service

Concerns summary The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.

John Grooby

All Responded

2014-0054 7 Feb 2014 Warwickshire

Warwickshire County Council

Concerns summary A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.

Daniel Jones

All Responded

2014-0049 3 Feb 2014 Dorset

Dorset Highways Management

Concerns summary Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed limits.

Amanda Vickers

All Responded

2014-0052 3 Feb 2014 Cumbria (North & West)

NHS Cumbria Clinical Commissioning Group

Concerns summary A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.

Ryan Clark

All Responded

2014-0057 3 Feb 2014 West Yorkshire (East)

National Offender Management Service

Concerns summary Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.

Lee Bonsall

All Responded

2014-0044 31 Jan 2014 Carmarthenshire & Pembrokeshire

Department of Health and Social Care

Concerns summary Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Action taken summary The Department of Health disputes that national guidelines restrict the repeat prescribing of citalopram, stating they are not rules and prescribing remains a clinical responsibility. They will, howev

Tallulah Wilson

All Responded

2014-0047 30 Jan 2014 London Inner (North)

Department of Health and Social Care

Concerns summary Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.

Action taken summary The Department of Health has launched an e-learning tool for professionals working with children and young people on mental health. They are also funding research into internet use and suicidal …

Umul Audu

All Responded

2014-0038 27 Jan 2014 London Inner (North)

University College London Hospitals NHS…

Concerns summary The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.

Action taken summary University College London Hospitals NHS Foundation Trust disputes the need to introduce transport heaters, stating their current standard measures for preventing hypothermia are adequate and in line w

Judith Marshall

All Responded

2014-0039 27 Jan 2014 York

Department of Health and Social Care NHS England Royal Pharmaceutical Society of Great B… +1 more

Concerns summary The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.

Action taken summary The General Pharmaceutical Council outlines its regulatory standards and inspection processes, stating it will continue to monitor pharmacies and take action where standards are not met. They are cons

Alfred Hodges

All Responded

2014-0033 24 Jan 2014 North Central & North East Wales

Conwy County Council

Concerns summary Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety check.

Action taken summary Conway Council has installed 105 linked smoke detectors, hired a full-time officer for a 6-month installation program, and provided refresher training for installers. They have also issued a briefing