UK Inquiry Tracker

Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

All Responded

2023-0105Deceased 24 Jul 2017 East Sussex

Birnberg Peirce Solicitors Department for Transport Health and Safety Executive +7 more

Concerns summary (AI summary) There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.

Noted (AI summary) The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches, and states that it can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. The Forum intends to update and expand the use of the WAID database and is seeking to identify suitable sources of funding for this development work. The council acknowledges the concerns and refers to previous reports and statements regarding beach management at Camber Sands, and states that restricting public use of beaches would be disproportionate. RoSPA states that it seeks to influence, inform, coordinate activity and advise within the existing structures for water safety, and states that significant landowners successfully manage sites with significant hazards to the public without noticeable impacts or blanket restrictions. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions, and will conduct an independent review of its accident prevention activity.

Richard Davies

Partially Responded

2017-0325 24 Jul 2017 Cambridgeshire and Peterborough

Bedfordshire Police Constabulary Cambridgeshire police forces Hertfordshire police forces +1 more

Concerns summary (AI summary) A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.

Action Taken (AI summary) The BCH APU is no longer using the un-bonded 5.56mm ammunition which was used in the present case and has amended its system of record-keeping to ensure that all decisions relating to the selection of ammunition are recorded on a single electronic system.

Ben Jukes

All Responded

2017-0335 24 Jul 2017 Manchester (City)

Ministry of Defence

Concerns summary (AI summary) The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.

Action Planned (AI summary) The need for absolute discretion during drug testing will be reiterated to units during initial notification.

Patricia Parker

Historic (No Identified Response)

2017-0454 24 Jul 2017 Milton Keynes

NHS England

Concerns summary (AI summary) Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.

Khuong Lam

Historic (No Identified Response)

2017-0455 24 Jul 2017 South Wales Central

Chief Medical Officer for Wales

Concerns summary (AI summary) Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of two escorts for patient safety.

Linda Baranowski

All Responded

2017-0341 22 Jul 2017 Hertfordshire

Hertfordshire Trading Standards National Food Crime Unit, Food Standard…

Concerns summary (AI summary) Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.

Action Planned (AI summary) Hertfordshire Trading Standards will liaise with national government agencies and regulators regarding food product safety, offering input into developing a national strategy if requested by the Food Standards Agency. The FSA Incidents Team investigated Mrs. Baranowski's case and the National Food Crime Unit has been actively working against the sale of dangerous food, including DNP, promoting awareness campaigns and monitoring the internet for sales.

James Allbones

Historic (No Identified Response)

2017-0336 21 Jul 2017 Nottinghamshire

Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS Tr…

Concerns summary (AI summary) A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.

James Harris

All Responded

2017-0334 21 Jul 2017 Birmingham and Solihull

Care First Class UK Limited Care Quality Commission

Concerns summary (AI summary) Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.

Noted (AI summary) Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; management staff are also monitoring records to address any issues arising. CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for a registered manager and ongoing assessments.

Pauline Taylor

Partially Responded

2017-0330 21 Jul 2017 West Yorkshire (West)

Arjo Huntliegh Care Quality Commission Department of Health and Social Care +6 more

Concerns summary (AI summary) Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.

Action Planned (AI summary) PAGB will provide a written submission to the MHRA by September 30th, 2017 regarding paraffin-containing products and will work with the MHRA, fire brigades, and other stakeholders to ensure clear and consistent communication about the risks. MHRA has liaised with ArjoHuntleigh to confirm risk mitigation factors are appropriate and are working to communicate important healthcare information to healthcare professionals and the public through established alert systems. MHRA were also aware of and highlighted the work undertaken by the National Patient Safety Agency (NPSA) in 2007 regarding emollients. Locala has shared learning from the case internally, raised awareness about paraffin-containing products in their monthly medicines management report, and is developing a flowchart, documentation, and training for staff to identify patients at risk and ensure further risk assessments are completed when circumstances change. NHS Improvement notified of the death in 2015 and included actions taken in response to the death in the Patient safety review and response report published in June 2017. The UK Homecare Association has provided information to homecare providers including a fact sheet prepared by the London Fire Brigade, an article in their magazine, and an email briefing regarding the fire risks of paraffin-based emollients.

Nina Maggs

All Responded

2017-0216 20 Jul 2017 Wiltshire and Swindon

Department for Transport Swindon Borough Council

Concerns summary (AI summary) The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.

Action Planned (AI summary) The council will commence stakeholder consultation on 18th September 2017 regarding proposals to improve pedestrian safety at the junction. Provisional arrangements have been made to assign resources to progress with the design and potential delivery of a scheme. The Department for Transport, while noting a lack of evidence, will consider with trade associations how to encourage signage on left-hand drive vehicles to alert pedestrians to the risks.

Ozeivo Akerele

All Responded

2017-0337 19 Jul 2017 Coventry

West Midlands Police

Concerns summary (AI summary) Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were inadequate.

Action Planned (AI summary) The case will be referred to the National Missing Persons Operational Group to consider amending guidance around how a search is co-ordinated in similar cases. This will provide clarity around the tasking of the search, what is being searched for, and the accurate recording of the search.

Edith Robinson

All Responded

2017-0452 19 Jul 2017 Manchester (North)

Department for Health

Concerns summary (AI summary) Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.

Action Taken (AI summary) The Trust is working towards seven day services in all hospitals and is implementing a program focusing on daily medical reviews. They have also implemented changes to improve documentation including audits and mandatory training, and adopted a Nursing Assessment and Accreditation System.

Ivy Mitchell

Partially Responded

2017-0453 18 Jul 2017 Manchester (South)

Fairfield View Care Centre Tameside Borough Council

Concerns summary (AI summary) Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.

Action Taken (AI summary) The care centre audited all documentation regarding falls and mobility, cascaded information to staff about completing relevant documentation, and is auditing care plans and daily records. Senior staff are undertaking a course on care planning at Tameside College.

Matthew Edwards

All Responded

2017-0451 17 Jul 2017 Manchester (South)

Tameside and Glossop Integrated Care NH…

Concerns summary (AI summary) Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.

Action Taken (AI summary) The Trust has addressed the issue of timely discharge summaries by clearing a backlog with extra resources. Training has been implemented and processes have been revised, and discharge lounges have been relocated and refurbished.

Sabrina Walsh

All Responded

2017-0449 14 Jul 2017 East Sussex

Department of Health and Social Care Sussex Partnership NHS Trust

Concerns summary (AI summary) The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.

Noted (AI summary) NHS England provides context regarding the use of CCTV in mental health units, referencing relevant guidance and the Sussex Partnership NHS Foundation Trust's consultation with patients and staff. They note the Trust's agreement to install CCTV in entrance areas. The Trust is implementing the installation of CCTV in the entrance areas of all 12 of its acute inpatient/PICU wards, including Woodlands.

Steffan Bonnot

Historic (No Identified Response)

2017-0450 14 Jul 2017 West Sussex

Ofsted

Concerns summary (AI summary) Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.

Edwin O’Donnell

All Responded

2017-0258 13 Jul 2017 Liverpool & Wirral

HM Prison and Probation Services

Concerns summary (AI summary) Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.

Action Taken (AI summary) The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT, and suicide and self-harm training is being rolled out to all staff.

Elaine Davison

Historic (No Identified Response)

2017-0444 12 Jul 2017 West Yorkshire (East)

National Tree Safety Group

Concerns summary (AI summary) A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading to an underestimation of its felling urgency.

John Wilson

Historic (No Identified Response)

2017-0445 12 Jul 2017 Manchester (South)

Beko Plc

Concerns summary (AI summary) The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.

Mark Berry

Historic (No Identified Response)

2017-0232 11 Jul 2017 Hampshire (Central)

Royal Hampshire County Hospital South Central Ambulance Service NHS Tru…

Concerns summary (AI summary) Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.

Doreen Willis

All Responded

2017-0439 11 Jul 2017 Plymouth Torbay and South Devon

Care Quality Commission

Concerns summary (AI summary) Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.

Noted (AI summary) The trust summarises the key learning outcomes from the agency review, pertaining to medicine management policies and processes for care homes. It references NICE guidance and the Electronic Transfer of Prescriptions (EPS) systems being introduced.

Margery Astill

Historic (No Identified Response)

2017-0440 11 Jul 2017 Leicester (City & South)

Leicestershire NHS Trust

Concerns summary (AI summary) Ineffective diary systems led to failures in referrals, the system for updating incident reports was unclear, communication with family members was inadequate, and there was a delay in attending to the patient after a fall.

Hannah Barney

Historic (No Identified Response)

2017-0442 11 Jul 2017 London Inner (South)

Department of Health Kings College Hospital NHS England

Concerns summary (AI summary) A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.

Catherine Roberts

Historic (No Identified Response)

2017-0076 7 Jul 2017 North Wales (East and Central)

Betsi Cadwaladr University Health Board

Concerns summary (AI summary) Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the Health Board, placing patients' lives at risk.

Sousse (Tunisia)

Historic (No Identified Response)

2017-0206 7 Jul 2017 London (West)

ABTA Civil Aviation Authority Department for Transport +1 more

Concerns summary (AI summary) Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.