UK Inquiry Tracker

Carl Foot

Historic (No Identified Response)

2015-0447 26 Oct 2015 London Inner (North)

HMP Pentonville

Concerns summary (AI summary) Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.

Wayne O’Neill

All Responded

2015-0444 26 Oct 2015 Worcestershire

Worcestershire Health and Care NHS Trust

Concerns summary (AI summary) There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.

Action Taken (AI summary) All patients prescribed anti-psychotic medication will receive a routine annual ECG as part of their care; the Lead Pharmacist will sample audit this by 31 January 2016. Training will be provided to the Nursing team regarding medicines that should indicate a referral for an ECG, and the issue of anti-psychotic medication and extended QT intervals will be included in HMP Long Lartin GP supervision session and the Mental Health MDT meeting.

Allan Beasley

Historic (No Identified Response)

26 Oct 2015 Birmingham and Solihull

Sunrise care home

Concerns summary (AI summary) Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.

Barry Thraves

All Responded

2015-0443 26 Oct 2015 Leicester City and South Leicestershire

Leicester Partnership NHS Trust Leicester City Council

Concerns summary (AI summary) Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.

Action Planned (AI summary) Adult Social Care will send letters to individuals waiting for assessments from an Adult Mental Health Team, explaining Adult Social Care's role and how to contact the team if the situation changes; case records across Adult Mental Health have been reminded of the importance of feeding back to the whole multi-disciplinary team and to carers, not solely the Registered Medical Officer. The LPT will review and update its DNA policy by March 2016; CMHTs are undergoing service redesign to remove internal barriers between the Outpatients Service and the wider CMHT, including a pathfinder project in North West Leicestershire CMHT to look at a multi-disciplinary team held caseload model with the aim to roll this out across all CMHTs by April next year.

Margaret Ferry

All Responded

2015-0450 23 Oct 2015 Sunderland

City Hospitals Sunderland NHS Foundatio…

Concerns summary (AI summary) The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.

Action Taken (AI summary) A new standing operational procedure has been developed to provide a comprehensive approach to inter-organisational referrals for plastic surgery opinions; it ensures that the referral is clearly documented, a suitable response is provided within clearly defined timescales, and it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team.

Hireiti Kuflesion

Historic (No Identified Response)

2015-0414 23 Oct 2015 Birmingham and Solihull

Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E +3 more

Concerns summary (AI summary) Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.

Samuel Gale

All Responded

2015-0454 23 Oct 2015 South Yorkshire (East)

HMP and YOI Doncaster

Concerns summary (AI summary) A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

Action Planned (AI summary) Policy changes have been made so that only a manager grade can close an ACCT, and ACCTs cannot be closed unless the case review comprises at least two people and all actions on the CAREMAP have been completed; HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved. NHS England is reviewing templates for first night screening and risk assessment as part of the deployment of a new Health & Justice Information System, with rollout expected from July 2016 to July 2017.

Richard Laco

All Responded

2015-0411 22 Oct 2015 London Inner (North)

CMF Limited Laing O’Rourke UK & Europe

Concerns summary (AI summary) Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.

Action Planned (AI summary) CMF Ltd will ensure lifting operations are planned by a qualified appointed person, use their native lift plan procedure, submit plans to the Principal Contractor for approval, explain plans to the lift team, and re-brief the team if the lift supervisor is absent or the plan is in force for more than 90 days; lifting will cease if conditions change. Laing O'Rourke issued a Safety Alert requiring sign-off by their Appointed Person for Lifting on all contractor lift plans and requires project teams to review high-risk activities monthly with 'Planned vs Actual' assessments.

Glenda Day

Historic (No Identified Response)

2015-0410 22 Oct 2015 Nottinghamshire

Nottinghamshire Healthcare NHS Trust

Concerns summary (AI summary) A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.

Harry Mellor

Partially Responded

2015-0409 22 Oct 2015 Nottinghamshire

Department of Health and Social Care General Medical Council Nottingham City Clinical Commissioning … +2 more

Concerns summary (AI summary) There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.

Noted (AI summary) The Department of Health acknowledges concerns about GP registration/de-registration, explains the current system and other opportunities for ensuring child healthcare, and notes the hospital's failure to follow up on missed appointments, suggesting the use of an IT system for automatic follow-up. PHE states it doesn't have a direct role in GP registration, notes NHS England can comment on the regulation and procedure, and has alerted the relevant NHS England team and the Director of Public Health; expects GP registration will form part of a review. The GMC outlines its role in setting standards for doctors but states it doesn't have a direct role in healthcare service design; it highlights existing guidance and ongoing work by other organisations (RCPCH) on clinical guidance for children with long-term conditions. The CCG is appointing an independent author to review GP involvement in the case as part of a serious case review and has requested assurance from specialist paediatric services that 'Did Not Attend' procedures are being effectively implemented; the review is due by March 2016.

Diane Knight

All Responded

2015-0408 22 Oct 2015 Exeter and Greater Devon

Devon Partnership Trust

Concerns summary (AI summary) The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.

Action Taken (AI summary) Devon Partnership NHS Trust will discontinue the practice of patients obscuring windows in bedroom doors, issue a patient safety alert, and is developing a Respect and Dignity Audit to consider privacy and patient safety.

David Baddeley

All Responded

2015-0451 21 Oct 2015 Manchester (South)

Greater Manchester NHS Area Team

Concerns summary (AI summary) Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.

Action Planned (AI summary) Practices will be reminded to screen new patients for serious psychiatric illness and ensure diagnoses are recorded, highlighted, and correctly coded when patients transfer to another practice; from June 2016, practices will be able to track records and see expected delivery dates.

Samantha Beach

Historic (No Identified Response)

2015-0413 21 Oct 2015 Gloucestershire

Gloucestershire Hospitals NHS Trust

Concerns summary (AI summary) The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community midwives, GPs, and the obstetric department, and the obstetric department was not involved when the patient attended the Emergency Department post-natally.

Dorothy Cooper

All Responded

2015-0412 21 Oct 2015 South Yorkshire (East)

Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust

Concerns summary (AI summary) Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.

Action Planned (AI summary) The Leeds Teaching Hospitals NHS Trust has re-circulated the pathway document, updated in October 2014, which highlights the need for completion of the referral form as fully and accurately as possible; the team has altered the MDT reply forms to state that responsibility for patient care remains with the referring team until the patient has been seen in Leeds. The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are collaboratively revising inter-provider transfer of care processes for cancer patients in West Yorkshire and expect to embed the revised processes by the end of February 2016; the Trust will embed the revised processes and ensure junior medical staff completing MDT pro formas remain well supported by the end of February 2016.

Erich Speilmann

Historic (No Identified Response)

2015-0389 20 Oct 2015 Essex

Essex Highways Agency

Concerns summary (AI summary) The quality of street lighting at the incident location was poor and may have contributed to the event.

William Abel

All Responded

2015-0406 20 Oct 2015 Leicester City and Leicestershire South

Leicester Partnership NHS Trust

Concerns summary (AI summary) Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.

Action Taken (AI summary) The Trust conducted a serious incident investigation and shared the results with the deceased's father. The Triage Car service manager and team manager reviewed decisions made on the night, and a new outcome of assessment and plan record form will be introduced for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015, with monitoring via clinical governance arrangements.

Kyle Hull

All Responded

2015-0379 19 Oct 2015 County Durham and Darlington

Darlington Cattle Mart

Concerns summary (AI summary) Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.

Action Planned (AI summary) The auction mart company plans to install CCTV with night vision and movement detection, linked to mobile phones of company management, but is currently seeking financing; a final decision is expected at the December board meeting.

Vasilis Ktorakis

All Responded

2015-0377 19 Oct 2015 London Inner (North)

Whittington Hospital NHS Trust

Concerns summary (AI summary) The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement in allowing passive descent, and a systemic issue in learning from incidents.

Action Taken (AI summary) The response details multiple actions already completed including educational supervision for the registrar involved, sharing learning points via newsletters and meetings, and implementing a meeting at the start of every maternity serious incident investigation. Planned actions include multidisciplinary meetings, feedback to staff, and communication from the Medical Director regarding record keeping.

Adrian Smith

Partially Responded

2015-0378 16 Oct 2015 Birmingham and Solihull

Heart of England NHS Foundation Trust NHS England

Concerns summary (AI summary) A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.

Action Planned (AI summary) The Trust will change the communication process for specialist radiological investigation queries by having the consultant radiologist speak directly with the senior neurosurgeon. A standard operating procedure (SOP) will be developed to articulate the strengthened process, and the family will be contacted directly.

Caroline Robey

Partially Responded

2015-0376 16 Oct 2015 Leicester City and Leicestershire South

West Leicester CCG East Midlands Ambulance Service NHS England +1 more

Concerns summary (AI summary) Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency admission.

Action Taken (AI summary) NHS England discussed the case at a Performance Advisory Group and requested reflection on record keeping and sepsis diagnosis/treatment in the next appraisal. The importance of diagnosing sepsis and the use of the sepsis screening tool has been highlighted through the local medical committee. A patient safety alert was issued, and the CCG will meet with the University Hospitals of Leicester to share experience/materials and provide support in sepsis management. A clinical newsletter was circulated in July 2015 to alert clinicians to learning points, and the Loughborough Urgent Care Centre is developing a Local Operating Procedure for multiple attendances.

William Tolen

All Responded

2015-0407 15 Oct 2015 Manchester (South)

Shawe Lodge

Concerns summary (AI summary) Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.

Action Taken (AI summary) Staff have received further supervision and training in relation to documentation, and instructions have been added to staff diaries. Staff have been requested that requests are stated clearly and that progress is recorded, and all nurses have discussed the need to enter details fully in the daily notes.

Alan Tear

All Responded

2015-0373 14 Oct 2015 Leicester City and Leicestershire South

University Hospitals of Leicester NHS T…

Concerns summary (AI summary) Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.

Action Taken (AI summary) The matron met with all nursing staff on the ward to discuss what had occurred in this case, emphasizing awareness of required observation frequency. The Interim Deputy Medical Director and Assistant Chief Nurse are rewriting the EWS training package, due for completion by the end of March 2016.

Nathaniel Phillips

All Responded

2015-0375 13 Oct 2015 Manchester (South)

Department of Health and Social Care

Concerns summary (AI summary) Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due to cost and preventing GPs from escalating care.

Noted (AI summary) The Department of Health acknowledges the coroner's concerns regarding brittle asthma not being covered by medical exemption certificates. It explains existing routes to exemption and refers to GMC guidelines on prescribing.

Catherine Findlay

Partially Responded

2015-0372 13 Oct 2015 Manchester (West)

Advisory Council on the Misuse of Drugs Home Office Minister of State for Crime Prevention

Concerns summary (AI summary) Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.

Action Taken (AI summary) The Minister notes the concern about MXP and refers to the Psychoactive Substances Bill creating a blanket ban on the supply of NPS. The government has launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users.

Mrs Withers

Historic (No Identified Response)

2015-0371 12 Oct 2015 Northampton

East Midlands Ambulance Service Freeth Cartwright Solicitors Kettering General Hospital NHS Trust

Concerns summary (AI summary) Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.