Recurring concern

Unreliable formal safety-incident management processes

First to latest report 29 May 2013 — 10 Mar 2026

Reports that mention this concern
103
Times this concern has been raised
129
Stated actions linked to this concern
182

What this concern includes

Includes failures of a formal organisational safety-incident or serious-incident management framework, including incident identification, grading, coordination, investigation, monitoring and control.

What is not included
  • Excludes failures limited to implementing corrective actions after incident learning has already been established.
  • Excludes generic organisational learning, governance or incident-reporting deficiencies where no serious-incident management process is identified.
  • Excludes the underlying clinical or operational hazard and failures in ordinary care that are not part of serious-incident management.
  • Excludes investigations concerning deaths, complaints, crime or regulatory matters where the reported concern is not the management of a serious or untoward incident.
  • Excludes operational emergency-response, rescue and event-planning protocols that are not part of a formal organisational safety-incident management framework.

Reports and published responses 103 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Elvon Paul Randolph Morton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify serious incidents and remediate sub-optimal practice

    Wider context from the report

    “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings. Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case. ”

    Source location

    Elvon Paul Randolph Morton · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.

    Verbatim wording from the response

    “Since November 2023, WXH have been in the process of implementing the Patient Safety Incident Response Framework. There is a very clear directive that unexpected deaths need to be reported via Datix and presented at Patient Safety Incident Review Meeting (PSIRM) so that an MDT decision can be made in terms of the correct learning response. In cases where care is thought to have led to the patient’s death a PSII will be undertaken (these investigations can take up to 6 months to complete). In other cases, an After-Action Review or SWARM should be undertaken, (where staff ‘swarm’ to review an incident) will be undertaken, these need to be completed within 12 weeks. In other cases, the PSIRM chair will request that the case be presented to M&M and the outcome reported back to PSIRM.”

    Source location

    Response from Barts Health
    Page 4 · response
    Published 14 May 2024

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.

    Verbatim wording from the response

    “WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, learning responses and other key documentation are submitted in a timely manner (including statements). A proposal has been prepared to recruit a learning from deaths lead, their primary responsibility would be to drive improvement with stakeholder engagement including families, MEs, and coroners.”

    Source location

    Response from Barts Health
    Page 4 · response
    Published 14 May 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recruit a learning-from-deaths lead to drive improvement and engage families, medical examiners and coroners.

    Verbatim wording from the response

    “WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, learning responses and other key documentation are submitted in a timely manner (including statements). A proposal has been prepared to recruit a learning from deaths lead, their primary responsibility would be to drive improvement with stakeholder engagement including families, MEs, and coroners.”

    Source location

    Response from Barts Health
    Page 4 · response
    Published 14 May 2024

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.

    Verbatim wording from the response

    “This patient’s death on 7 December 2022 was unexpected and was reported as an incident via the Datix reporting system but it was not presented for multidisciplinary team (MDT) discussion as a serious incident. The fail safe whereby a mortality and morbidity meeting triggers Serious Incident Review Assurance Panel (SIRMAP) discussion did not happen because although learning was identified the outcome was not felt to have been due to failures in care. Following a prompt from HM Coroner via the legal team, the case was presented to SIRMAP in July 2023 and the panel identified learning but did not find that the outcome could have been altered in this case.”

    Source location

    Response from Barts Health
    Page 4 · response
    Published 14 May 2024

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The primarily local concerns are for Barts Health NHS Foundation Trust to address.

    Verbatim wording from the response

    “In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 14 May 2024

    Open published response

  2. Suffolk

    AI-generated summary

    Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate PSIRF processes for addressing serious patient incidents

    Wider context from the report

    “3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT. ”

    Source location

    Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to define which statements are to be taken for serious patient incident investigations

    Wider context from the report

    “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust. ”

    Source location

    Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to retain recordings of calls for serious patient incident investigations

    Wider context from the report

    “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust. ”

    Source location

    Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.

    Verbatim wording from the response

    “4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 15 April 2024

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Norfolk and Suffolk NHS Foundation Trust is responsible for addressing the care concerns and providing details of PSIRF implementation.

    Verbatim wording from the response

    “I note that your Report has also been addressed to Norfolk and Suffolk NHS Foundation Trust who are the appropriate organisation to answer the majority of the concerns raised in your Report. NHS England has engaged with the Trust on the issues raised in your Report about Ellen’s care and have been sighted on the action plan and statement submitted to you at inquest. We note from the Trust that their actions include:”

    Source location

    2024-0184 - Response from NHS England
    Page 1 · response
    Published 15 April 2024

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Saffra Harriett Winn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 24 July 2022, Saffra Harriett Winn was found unconscious and not breathing on pavement between two high-rise blocks of flats after falling or jumping from a window of her flat. The report raised concerns that Sheffield City Council had not risk-assessed the windows or safety latches after two tenant fatalities, and lacked a formal process for investigating and assessing risks following catastrophic injuries or deaths in its social housing.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing

    Wider context from the report

    “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death. More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest. ”

    Source location

    Saffra Harriett Winn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a procedure and reporting framework for recording high-rise falls fatalities and near misses and identifying when window safety reports are required.

    Verbatim wording from the response

    “SCC has also instigated a new procedure and reporting framework which will log all reported fatalities and near misses from falls from high rise council accommodation and guidance outlining when a safety report is required on the functionality of the windows and restrictors. This guidance is currently going through the appropriate approvals process and will again be in place by 14th June 2024. Thankfully I can report that there have been no further fatalities from falling from tower blocks since the incident in December 2023. This guidance will set out clear roles and responsibilities from the role of the Responsible Person, normally a Council Director, to who undertakes what function and when. It is also proposed that each fatality is reported to the Council’s Housing Policy Committee.”

    Source location

    Response from Sheffield City Council
    Page 3 · response
    Published 3 April 2024

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Alexander Vitali Lyalyushko · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alexander Vitali Lyalyushko took his own life by hanging at his home on 2 January 2023, where he lived alone. A request from his GP for mental health service involvement in November 2022 was not actioned, and he was not receiving mental health services at the time of his death. The report also identified deficiencies in the initial review and incident investigation following his death, including failure to identify the unactioned request and failure to consult his family.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify un-actioned service-involvement requests in post-death incident reviews

    Wider context from the report

    “1. Inadequate review and incident investigation following a death Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. ”

    Source location

    Alexander Vitali Lyalyushko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inaccurate identification of required improvements as good practice in post-death incident reviews

    Wider context from the report

    “1. Inadequate review and incident investigation following a death Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. ”

    Source location

    Alexander Vitali Lyalyushko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consult families about concerns that could direct post-death incident reviews

    Wider context from the report

    “1. Inadequate review and incident investigation following a death Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. ”

    Source location

    Alexander Vitali Lyalyushko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete the further review and addendum to incorporate newly identified information and issues from the inquest findings.

    Verbatim wording from the response

    “record and therefore unavailable to the author of the CNR. This information became known about in January 2024 and agreed that this would be dealt with via a statement from the relevant team leader. This statement was to confirm that this referral was not available or known to the author of the CNR, confirm what had occurred, confirm what should have happened according to procedure, and what had since been put in place to reduce risk of recurrence.”

    Source location

    Response from Nottinghamshire Healthcare NHS FT
    Page 2 · response
    Published 13 August 2024

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share the completed review addendum with the coroner and the deceased’s family.

    Verbatim wording from the response

    “It was subsequently agreed at the inquest that a further review would be undertaken and addendum to the report added to take into account this information that was not known at the time of the original CNR, as well as the additional points raised within the findings and conclusion document provided to the Trust. This is being undertaken and nearing completion. We will share this once completed with you and the family of Alexander, who have been involved in the onward investigation process. Once completed we will be better sighted to understand the wider lessons learnt and actions required to mitigate future occurrence and ensure the correct oversight is deployed.”

    Source location

    Response from Nottinghamshire Healthcare NHS FT
    Page 2 · response
    Published 13 August 2024

    Open published response

  5. East London

    AI-generated summary

    Regina Olufunmilola Ademiluyi · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Regina Olufunmilola Ademiluyi was an 83-year-old woman who was bed-bound following surgery for a broken hip and died in March 2024 after declining cognition and physical health, malnutrition, a grade 4 sacral pressure ulcer and an aspiration incident. The report raised concerns that state-funded domiciliary care was not provided, and that the NHS Trust and local authority did not adequately assess or respond to safeguarding, mental-capacity and carer-support concerns.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the local authority to undertake meaningful significant event analysis of care failings

    Wider context from the report

    “2. Despite the death of Mrs Ademiluyi’s occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the Local Authority into the failings in care by the time of the inquest almost a year later. It was suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client. ”

    Source location

    Regina Olufunmilola Ademiluyi · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.

    Verbatim wording from the response

    “Action: | By who: | By when: 1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024 | Team Manager Neighbourhood Team | 27.03.24 1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:”

    Source location

    Response from London Borough of Newham
    Page 1 · response
    Published 25 March 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.

    Verbatim wording from the response

    “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024 1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024”

    Source location

    Response from London Borough of Newham
    Page 2 · response
    Published 25 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.

    Verbatim wording from the response

    “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024 1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024”

    Source location

    Response from London Borough of Newham
    Page 2 · response
    Published 25 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.

    Verbatim wording from the response

    “double incontinence). Alongside this we are eager to convene a shared learning event with multi-disciplinary staff from across both organisations to explore the themes identified in Mrs Ademiluyi’s case from a clinician/practitioner perspective. These discussions are being progressed separately with our counterparts at the Trust.”

    Source location

    Response from London Borough of Newham
    Page 5 · response
    Published 25 March 2024

    Open published response

  6. County Durham and Darlington

    AI-generated summary

    Linda Louise Banks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in completing serious incident investigations

    Wider context from the report

    “(2) The Serious Incident Investigation into the care received by Linda was not completed until the end of January 2023, some 9 months after the death. This is neither timely nor responsive. Despite reassurances given that the Trust are working to eradicate such delays, in response to a series of previous PFD reports issued by the Coroners of Durham and Darlington, there are still cases coming to the attention of the Coronial service where Serious Incident Investigations are significantly delayed in excess of the 60 day NHS framework. ”

    Source location

    Linda Louise Banks · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to preserve evidence while memories are fresh during serious incident investigations

    Wider context from the report

    “(3) As previously reported the concern in relation to the delays in such investigations and any subsequent necessary action required, is twofold. Firstly, the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh. Secondly, because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly. ”

    Source location

    Linda Louise Banks · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The PFD appears to arise from unrelated advice about a future investigation, not outstanding concerns from evidence heard at this inquest.

    Verbatim wording from the response

    “It was therefore disappointing to receive a further PFD on this matter. I was further confused that the PFD in this case appears to have been issued in relation to you being advised on another unrelated matter that an SII would not be completed until January 2024, when the death occurred in October, and not due to any outstanding concerns in relation to the evidence heard at this inquest.”

    Source location

    Response from Tees, Esk and Wear Valleys NHS Foundation Trust
    Page 2 · response
    Published 28 December 2023

    Open published response

  7. Inner North London

    AI-generated summary

    Glenn Anthony LOCKWOOD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Glenn Anthony Lockwood, a known drug user receiving opiate replacement treatment, was found unresponsive after a suspected overdose on 14 April 2023 and later suffered a cardiac arrest. Despite hospital treatment, he died on 2 June 2023; the inquest concluded that his death was drug related, with mixed drug toxicity recorded as the medical cause. Concerns included whether Pregabalin abuse risks were sufficiently monitored and whether prescribing and record-keeping issues had been fully investigated and addressed.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Serious Event Analysis failing to fully explore relevant risks

    Wider context from the report

    “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

    Source location

    Glenn Anthony LOCKWOOD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Practice could not arrange a timely SEA because it received no hospital notification or medical cause of death until after the inquest.

    Verbatim wording from the response

    “Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood’s death until a letter dated 30 June 2023 was received from the Senior Coroner’s officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner’s office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner’s investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner.”

    Source location

    Response from The Limehouse Practice
    Page 4 · response
    Published 6 December 2023

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    Sasha Honey MISHABI · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sasha Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out a serious incident investigation when records indicate a relevant pre-admission incident

    Wider context from the report

    “2. SAH Governance, Quality Assurance and Serious Incident processors a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted. b. No serious incident investigation had been carried out by SAH into Mr. Mishabi's death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a statement from ████████ of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023. c. ████████ SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work. ”

    Source location

    Sasha Honey MISHABI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. County Durham and Darlington

    AI-generated summary

    Sarah Elizabeth Holmes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sarah Elizabeth Holmes, who had a history of mental health difficulties and self-harm, was found dead after discharge home following a mental health assessment; the medical cause of death was recorded as asphyxia. The principal concern was the substantial delay in the Trust’s serious incident investigation, which remained incomplete more than a year after her death and was described as neither timely nor responsive. The report also raised concern that such delays could allow lethal hazards to persist and compromise investigations intended to prevent similar deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete serious incident investigations in a timely and responsive way

    Wider context from the report

    “(1) The serious incident investigation by the Trust has been substantially delayed. Sarah died on the 10th of July 2022 and the Trust confirmed to the Coroner’s service that there was to be a serious incident investigation on the 26th July 2022. The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months and on the 13th of March 2023 as this remained the position I listed this case for inquest on the 24th April 2023. On the 17th April 2023 I was alerted by deceased’s family to possible progress in respect of the serious incident investigation in this case, subsequent to their formal complaint to the Trust. After making enquiries of the Trust I was informed that the report would be available at the end of May 2023 and I therefore acceded to a family request to adjourn the final hearing given the short delay this would cause. On the 25th of April 2023 the Coronial service was informed that in fact that it was unlikely that the report would be finalised by May and would be ‘likely end of July/August time’. On the 26th of June I was informed that the report would now not be available until the ‘end of September/beginning of October’ and that the initial dates given were “too ambitious”. The case was listed to commence on the 16th of November 2023 on that basis. On the 28th of July the deceased’s family notified me of a likely further delay in the report being available due to the author’s sick leave from work. The Trust offered reassurance that the report remained due ‘end of September/beginning of October’. On the 28th of September a Pre Inquest Review Hearing was held in relation to a separate discrete issue and I was informed that the report was to be further delayed and would not be available until the end of October. (2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again. (3) If the final version report is received by the end of October it will be some 15 months since Sarah’s death and some 13 months outside the NHS framework. This is neither timely nor responsive. (4) I have previously issued a PFD report in relation to this issue as has the Senior Coroner for Durham and Darlington, Mr Chipperfield, who stated that Tees Esk and Wear Valleys NHS Foundation Trust routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths. (5) I am concerned that these dangers persist, despite the Trust’s response to previous PFD reports and their assurances that remedial action was being taken to eradicate the delays, and as a result it is my statutory duty to make this further report. ”

    Source location

    Sarah Elizabeth Holmes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. East London

    AI-generated summary

    Donna Levy · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake an adequately scoped serious investigation of community care incidents

    Wider context from the report

    “6. The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time. ”

    Source location

    Donna Levy · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the case at the Pressure Ulcer Assurance Group to identify further care gaps and learning.

    Verbatim wording from the response

    “• Undertake a review of this case at the Pressure Ulcer Assurance Group to identify any further gaps in care and learning.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure incident reports capture concerns across integrated services.

    Verbatim wording from the response

    “• Ensure incident reports include concerns across integrated services.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement PSIRF governance processes, including PSIG review of whether incidents require investigation and the appropriate investigation form.

    Verbatim wording from the response

    “With the introduction of the new Patient Safety Incident Response Framework, this has now changed. This framework includes new processes such as the Patient Safety Incident Report Group Forum (PSIG) that provides for greater and more detailed review of whether an investigation is needed and what form that will take. The PSIG is a NELFT wide meeting headed by the Executive Chief Nursing Officer and attended by, but not limited to, representatives at various levels from the different Directorates, Directors, Assistant Directors, Operational Leads, the Legal Team and the Patient Safety Team.”

    Source location

    Response from North East London Foundation Trust
    Page 3 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate all pressure ulcers associated with sepsis through full Patient Safety Incident Investigations.

    Verbatim wording from the response

    “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

    Source location

    Response from North East London Foundation Trust
    Page 3 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide Directorate oversight and expert review of category 2–4 pressure-ulcer incidents and stronger or deep-tissue injuries.

    Verbatim wording from the response

    “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

    Source location

    Response from North East London Foundation Trust
    Page 3 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish multidisciplinary pressure-ulcer review panels and thematic learning through PSIG and the Pressure Ulcer Assurance Group.

    Verbatim wording from the response

    “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

    Source location

    Response from North East London Foundation Trust
    Page 3 · response
    Published 8 September 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CQC criminal enforcement is unavailable because the incident does not meet the relevant enforcement threshold.

    Verbatim wording from the response

    “In addition, CQC reviewed the incident in line with their specific incident guidance and assessed that it does not meet the threshold for CQC to consider using its criminal”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 8 September 2023

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026