UK Inquiry Tracker

Ann Maguire

All Responded

2017-0417 22 Nov 2017 West Yorkshire (East)

Office for Standards in Education, Chil…

Concerns summary (AI summary) There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review and report on how schools prevent weapons from being brought onto premises.

Action Planned (AI summary) Ofsted will consider giving more focus to protecting pupils and staff from violent attack as part of its review of the inspection framework for education inspections which is expected to be in place for September 2019; the Safeguarding Group has been made aware of the coroner's concerns and these will be taken into account in future reviews.

Tomas Kelly

All Responded

2017-0412 22 Nov 2017 Nottinghamshire

Chief Medical Officer Committee on Vaccination and Immunisati… National Clinical Director for Children… +1 more

Concerns summary (AI summary) Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.

Action Planned (AI summary) The JCVI is currently reviewing its advice on varicella vaccination and will consider including children with Down’s syndrome in the list of high-risk groups during meetings in 2018.

Peter King

All Responded

2017-0414 20 Nov 2017 Kent (Central & South East)

East Kent Hospitals University NHS Trust

Concerns summary (AI summary) Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.

Action Taken (AI summary) The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full time band 4 Associate Practitioner for Falls Prevention joined the team in September 2017.

Harold Wonfor

All Responded

2017-0408 20 Nov 2017 Kent (Central & South East)

East Kent Hospitals University NHS Trust

Concerns summary (AI summary) Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.

Action Taken (AI summary) The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full time band 4 Associate Practitioner for Falls Prevention joined the team in September 2017.

Sarah Kiff

All Responded

2017-0407 20 Nov 2017 Manchester (North)

Stonefield Street Surgery

Concerns summary (AI summary) GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Action Taken (AI summary) The practice has produced annual audit reports around new cancer diagnoses for several years; the practice has a new written policy around methodology for undertaking HVS and the recording of findings, and a new policy that describes internal referral processes between clinicians.

Mildred Griffiths

All Responded

2017-0400 17 Nov 2017 Birmingham and Solihull

St Giles Nursing Home

Concerns summary (AI summary) The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.

Noted (AI summary) Avery Health Group states they will continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.

Anthony Grant

All Responded

2017-0410 16 Nov 2017 London Inner (North)

Royal Life Saving Society UK

Concerns summary (AI summary) A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and static positioning. The coroner suggests using the CCTV footage as a national training tool to improve vigilance.

Action Planned (AI summary) RLSS UK will raise swimming pool safety matters at the CIMSPA annual conference, which will host the launch of the HSE's revised guidance, Managing Health and Safety in Swimming Pools (HSG 179). The RLSS UK, CIMSPA and ukactive are committed to providing a summary of the changes and reminders about lifeguard vigilance.

Doreen Wilkins

All Responded

2017-0399 16 Nov 2017 Manchester (South)

Comfort Call Limited

Concerns summary (AI summary) Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Action Taken (AI summary) Tameside Borough Council agreed to pay an additional sum for travel time between care assignments, allowing Comfort Call to include travel time as a separate element in staff rotas. This aims to increase direct contact time between care workers and service users.

Timothy Smedley

All Responded

2017-0398 16 Nov 2017 Manchester (North)

Department of Health and Social Care

Concerns summary (AI summary) Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due to an apparent lack of awareness regarding their complex needs.

Noted (AI summary) The Department of Health acknowledges the concerns regarding access to NHS records and services for individuals with co-occurring mental health and substance misuse conditions. They reference existing guidance and reviews on information sharing and integrated care pathways, highlighting the responsibility of local commissioners and providers.

Stephanie Cave

All Responded

2017-0361 16 Nov 2017 South Wales Central

Welsh Government Ludlow Street Healthcare

Concerns summary (AI summary) Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm prevention.

Action Planned (AI summary) Heatherwood Court Hospital will review and update its Levels of Observation Policy and current enhanced observation recording documentation. They will introduce amended documentation for a 2-week trial and update the current training package to include video and exemplar copies of completed documentation. Healthcare Inspectorate Wales (HIW) completed an inspection of Heatherwood Court and raised concerns about observation of patients. In response, Heatherwood Court reviewed training and amended observation recording sheets. The Welsh government sent copies of the Code of Practice on the Mental Health Act to Heatherwood Court and all units managed by Ludlow Street Healthcare.

Kathleen Smith

All Responded

2017-0397 14 Nov 2017 Manchester (South)

Borough Care

Concerns summary (AI summary) The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.

Action Taken (AI summary) Borough Care has introduced a weekly form for managers to report significant incidents to the Head of Care, discussed in weekly Care & Quality meetings, with Area Support follow-up.

Brian Stannard

All Responded

2017-0394 14 Nov 2017 Norfolk

Norfolk & Suffolk NHS Trust

Concerns summary (AI summary) Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due to high workload, and underutilised computer systems also raised concerns.

Action Planned (AI summary) The Trust is engaged in a program to improve record-keeping, including risk assessments and care plans, with active monitoring at all levels. They are also working with business change and training specialists to develop staff use of the Lorenzo electronic patient record system and with system suppliers to improve its performance.

Steven Jones

All Responded

2017-0357 14 Nov 2017 South Yorkshire (East)

Beech Cliffe Grange Care Homes

Concerns summary (AI summary) Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.

Disputed (AI summary) Beech Cliffe disputes the coroner's conclusion that deficiencies in care may have contributed to the death, arguing that evidence presented at the inquest suggested otherwise. They state that the resident's GP was happy to proceed with an appointment and that staff considered the resident's needs when making decisions about attending appointments.

Jeff Antwis

All Responded

2017-0392 13 Nov 2017 Shropshire, Telford & Wrekin

South Staffordshire and Shropshire NHS …

Concerns summary (AI summary) A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and conducted subjective risk assessments, further compounded by transitioning services and possible masking of symptoms.

Action Taken (AI summary) The Trust highlights several actions taken in response to concerns raised, including reflective learning sessions, improved communication between team members, crisis team support within the home, implementation of electronic patient records, training on assessment documentation, and new service availability through Kooth and The Childrens Society. They also plan to review cases and fill vacant posts and develop a joint crisis pathway by June 2018.

Graeme Flatman

All Responded

2017-0393 10 Nov 2017 Newcastle Upon Tyne

Cumbria County Council

Concerns summary (AI summary) The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph speed limit on this challenging single carriageway road.

Action Planned (AI summary) Cumbria County Council will review signage at the collision location with the police and install any measures before the end of March. They will also look at the appropriateness of the 60 mph speed limit, but any changes will require a consultation and legal process taking at least 6 months.

Darren Powney

All Responded

2017-0346 10 Nov 2017 Sunderland

North East Ambulance Service NHS Trust

Concerns summary (AI summary) Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.

Action Taken (AI summary) The Ambulance Service has disseminated a briefing and memorandum to staff specifying procedures for warning markers on properties, is rolling out THRIVE training to Emergency Operations Centre staff, has provided dynamic risk assessment training and conflict resolution training to operational staff, and has developed dashboard stickers for police assistance. They are also auditing staff's knowledge of the JOP and have disseminated the Regulation 28 report to other Ambulance Trusts.

Timothy Atkins

All Responded

2017-0265 9 Nov 2017 Portsmouth and South East Hampshire

Portsmouth City Council

Concerns summary (AI summary) A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.

Action Planned (AI summary) Portsmouth City Council is working to improve transport routes and safety for cyclists on the Eastern Corridor, including widening and straightening the cycle path across the Burrfields Road junction, with work starting in early 2018. They have also obtained agreement to cut back a hedge along the cycle path.

Daisy French

All Responded

2017-0264 9 Nov 2017 South Yorkshire (West)

Department of Health and Social Care

Concerns summary (AI summary) The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for 16 to 18 year olds, and the appropriateness of placing under 18s in adult crisis houses or supported living without staff.

Noted (AI summary) Sheffield Health and Social Care NHS Foundation Trust and Sheffield Children's NHS Foundation Trust are working jointly, updating team protocols to ensure young people returning home to independent or supported living receive contact within 24 hours of A&E discharge. They have also identified an Operational Director Lead and will participate in a city-wide review, expecting a report between March and May 2018. The Department of Health acknowledges the concerns and explains the national position on transitioning between children's and adult mental health services, referencing NICE guidelines and NHS England's financial incentives. They note that local NHS organisations are responsible for reviewing local health services and mention actions taken by the NHS in Sheffield, including training, a Section 136 suite, and a Mental Health Liaison Consultant. They also note a safeguarding review to be completed by April 2018.

Ryan Vout

All Responded

2017-0376 6 Nov 2017 Nottinghamshire

NHS England Department for Health Nottingham County Council +5 more

Concerns summary (AI summary) There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.

Noted (AI summary) Nottinghamshire County Council has developed a more robust process for communicating demographics and essential risk information in relation to s135(1) warrants between AMHPs and the Police, including a typewritten document sent electronically by the AMHP. They are also exploring a dedicated conveyance service for people detained under the Mental Health Act. EMAS acknowledges its responsibility to provide timely ambulance service for patients with mental health needs. EMAS plans to adapt its operating model with an urgent care tier, which will go live across all five counties on 2 April 2018. The Department of Health acknowledges the concerns raised, focusing on discharge planning and transport for patients sectioned under the Mental Health Act. They state that these matters are operational and for local NHS services to determine, referencing the Crisis Care Concordat.

Harminder Dhillon

All Responded

2017-0266 6 Nov 2017 Bedfordshire and Luton

Network Rail

Concerns summary (AI summary) The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.

Action Planned (AI summary) Network Rail is developing additional enhancements targeting accidental and deliberate misuse at Automatic Half Barrier Crossings (AHBCs). The Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019.

John Nichols

All Responded

2017-0344 2 Nov 2017 Norfolk

Eastgate Residential Care Homes King's Lynn Residential Care Homes

Concerns summary (AI summary) The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Action Taken (AI summary) Kings Lynn and Eastgate Residential Care Homes engaged a fire consultant to observe fire drills, amended the pre-assessment form to include questions on distress caused by fire alarms, and revised the PEEP form. They have also amended the Group's Fire Drill Procedure and implemented relevant training.

Gordon Penistan

All Responded

2017-0313 31 Oct 2017 Hampshire (Central)

Adult Social Services

Concerns summary (AI summary) Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.

Action Taken (AI summary) ADASS circulated a confidential briefing regarding the coroner's report to all 153 local authorities with responsibility for adult social care via their news bulletin.

Kate Pierce

All Responded

2017-0312 31 Oct 2017 North Wales (East & Central)

Betsi Cadwaladr University Health Board

Concerns summary (AI summary) There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.

Action Taken (AI summary) The University Health Board confirms that it has a formal policy about discharging children from the children's assessment unit, and has altered the parent discharge information to explicitly state parents may escalate their desire to have a second opinion.

Douglas McTavish

All Responded

2017-0311 31 Oct 2017 North Wales (East & Central)

Whirlpool (UK) Appliances

Concerns summary (AI summary) Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too reluctant to rely on 'soft data' such as reported fires. Additionally, public awareness of the risk of spontaneous combustion may be insufficient.

Action Taken (AI summary) Whirlpool will support initiatives to raise consumer awareness of risks such as spontaneous combustion and has added relevant usage instructions to the 'Register my appliance' website.

Bernard Hender

All Responded

2017-0311-wp25922 31 Oct 2017 North Wales (East & Central)

Whirlpool (UK) Appliances

Concerns summary (AI summary) Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.

1 response from Whirlpool UK Appliances Limited