UK Inquiry Tracker

Frances Cappuccini

All Responded

2017-0020 27 Jan 2017 Kent (North-West)

Maidstone and Tunbridge Wells NHS Trust

Concerns summary (AI summary) Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.

Action Taken (AI summary) The Trust detailed standard practice for checking placenta removal and monitoring blood loss after caesarean sections. They described actions to improve diagnosis and treatment of Postpartum Haemorrhage (PPH), including training, equipment, PPH boxes and proformas. Also described documentation training and audits for staff.

Albie Marlow

All Responded

2017-0015 26 Jan 2017 Bedfordshire and Luton

Luton and Dunstable Hospital

Concerns summary (AI summary) A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.

Action Taken (AI summary) The hospital revised its VBAC form to incorporate a full clinical assessment including abdominal palpation and a vaginal examination for women undergoing IOL with a history of previous caesarean. Actions relating to improving the timeliness of epidurals and decision making around non-elective caesarean sections have been completed and implemented.

Raymond Pollard

All Responded

2017-0023 25 Jan 2017 Brighton and Hove

Brighton and Sussex University Hospital…

Concerns summary (AI summary) A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.

Action Planned (AI summary) The Trust's Head of Nursing reviewed the concerns and will share the learning with staff in Respiratory Medicine through sessions focusing on discharge procedures, responding to changes in patient NEWS scores, and appropriate documentation. Mr Pollard's care will be explored again at the next Respiratory Morbidity and Mortality Meeting and raised at the Trust-wide Deteriorating Patient Steering Group meeting.

Michael Parke

All Responded

2017-0025 18 Jan 2017 Cumbria

Department of Health and Social Care North Cumbria University NHS Trust: NHS…

Concerns summary (AI summary) Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.

Action Planned (AI summary) The Department of Health acknowledges the need for consistent implementation of patient safety requirements for nasogastric tubes. They are considering the evidence and economic implications of routine pH testing and will consider mandating it if the evidence supports it. The DH also highlights NIHR funding for a location-indicating naso-gastric tube being developed by the University of Hull. The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 and reported to the public Board meeting in March 2017.

Amanda Coulthard

All Responded

2017-0024 18 Jan 2017 Cumbria

Department of Health and Social Care North Cumbria University NHS Trust: NHS…

Concerns summary (AI summary) Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.

Action Planned (AI summary) The Department of Health acknowledges concerns about nasogastric tube misplacement and refers to ongoing work, including an NIHR-funded project at the University of Hull to develop a location-indicating NGT. The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 and reported to the public Board meeting in March 2017.

Natalie Gray

All Responded

2017-0003 13 Jan 2017 Mid Kent and Medway

Kent and Medway NHS

Concerns summary (AI summary) Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information was not consistently recorded.

Action Taken (AI summary) The Trust has implemented steps to support discharge from in-patient services, including using a countdown to discharge tool and strengthening links between CMHT and CRHT teams. The Trust is improving relationships with Kent Police by designating a third police officer to the acute service line and holding quarterly executive liaison meetings.

Sarah Tyler

All Responded

2017-0002 13 Jan 2017 North Wales (East and Central)

Betsi Cadwaladr University Health Board

Concerns summary (AI summary) Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.

Action Planned (AI summary) The Health Board is implementing an Unscheduled Care Plan in 2017/18 to improve waiting times for hospital admissions and reduce bed occupancy. The plan includes targets for each section and will be overseen by a Health Board-wide Transformation Group, with progress monitored monthly and by Welsh Government.

Jennifer Clark

All Responded

2017-0001 12 Jan 2017 Bedfordshire and Luton

Watford General Hospital

Concerns summary (AI summary) The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.

Action Planned (AI summary) The Trust states that it has adequate neonatal facilities but acknowledges that the Neonatal Unit requires modernisation. The Trust Board approved a redevelopment plan including the NICU and the Strategic Outline Case is awaiting consideration.

Charles Rendell

All Responded

2017-0006 11 Jan 2017 Berkshire

Bayer Plc

Concerns summary (AI summary) There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.

Noted (AI summary) Bayer states that patient safety is taken very seriously. They reviewed reports of psychiatric effects associated with ciprofloxacin and believe the UK product information includes an appropriate warning to advise prescribers and patients. The MHRA reviewed the information and considers that the product information for Ciproxin provides up-to-date information on the risk of mental disturbances. They will review all UK Package Leaflets for generic ciprofloxacin products to ensure consistent presentation of this information.

Emily Voukelatou

All Responded

2017-0004 11 Jan 2017 London Inner (North)

Camden and Islington NHS Trust

Concerns summary (AI summary) The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.

Action Taken (AI summary) The Trust stresses the importance of family input and states it is routinely assessed, with patient consent, throughout the care pathway. The trust issued guidance to staff at North Camden Crisis House to ensure that numbers and contact details are clearly provided to families.

David Moran

All Responded

2017-0008 6 Jan 2017 Cheshire

5 Boroughs NHS Foundation Trust

Concerns summary (AI summary) The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.

Action Taken (AI summary) The Trust has implemented a telephone system for the Assessment Team, piloted in Warrington in December 2016 and due Trust-wide by April 2017. All information relating to patients and their referrals must be documented within the electronic patient recording system (RiO), and a senior clinical member of staff reviews all referrals daily.