Recurring concern

Unreliable formal safety-incident management processes

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First reported 29 May 2013•Latest report 10 Mar 2026

Definition

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.

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: 103
Individual concerns: 129
Date range: 2013–2026
Stated actions: 182

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care16

Barking, Havering and Redbridge University Hospitals NHS Trust10

NHS England10

Care Quality Commission9

Barts Health NHS Trust5

Tees, Esk and Wear Valleys NHS Foundation Trust5

East London NHS Foundation Trust3

Greater Manchester Mental Health NHS Foundation Trust3

Midlands Partnership University NHS Foundation Trust3

Tameside and Glossop Integrated Care NHS Foundation Trust3

General Medical Council2

Great Western Hospitals NHS Foundation Trust2

Leicestershire Partnership NHS Trust2

National Institute for Health and Care Excellence2

Norfolk and Suffolk NHS Foundation Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

15 May2022
Surrey
Concerns raised1
1. Delayed and incomplete serious incident investigations
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.
  Stated by Care Quality CommissionStated completed
2. Action
  Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
  Stated by NHS EnglandStated completed
3. Action
  Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
  Stated by NHS EnglandStated completed
1. Action
  Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
  Stated by The Children's TrustStated in progress
2. Action
  Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
  Stated by The Children's TrustStated completed
Respondent positions 1
1. Position
  Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
AI-generated summary

Connor Samuel Timothy Wellsted · 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

Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.

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
Delayed and incomplete serious incident investigations
Wider context from the report
“3. Probity and Investigation by the Children’s Trust, Tadworth The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed. Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death. The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant. ”
Source location
Connor Samuel Timothy Wellsted · 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
Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.

Verbatim wording from the response
“All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.”

Source location
Response from CQC
Page 4 · response
Published 17 May 2022
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 the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.

Verbatim wording from the response
“In terms of investigation, the NHS England Patient Safety Incident Response Framework in July 2022. The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract, and as such is mandatory for services provided under that contract and will include Providers such as The Children’s Trust at Tadworth Court.”

Source location
Response from NHS England
Page 2 · response
Published 17 May 2022
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
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.

Verbatim wording from the response
“I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.”

Source location
Response from NHS England
Page 2 · response
Published 17 May 2022
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
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.

Verbatim wording from the response
“In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.”

Source location
Response from The Children's Trust
Page 8 · response
Published 17 May 2022
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
Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.

Verbatim wording from the response
“We accept that we should have thoroughly examined the potential role of the cot bumper in our initial investigation. With hindsight we were too quick to rule the bumper out based on the post-mortem findings. Our learnings here are reflected in the updates we have since made to our “Incident Reporting and Investigation, including Duty of Candour Policy”.”

Source location
Response from The Children's Trust
Page 9 · response
Published 17 May 2022
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
Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.

Verbatim wording from the response
“All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.”

Source location
Response from CQC
Page 4 · response
Published 17 May 2022
Open published response
22 Apr2022
Birmingham and Solihull
Concerns raised1
1. Failure of serious incident investigations to identify and implement critical lessons
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Amend 72-hour and team incident reports to document lessons learned and recurrence-prevention actions in greater detail.
  Stated by Priory GroupStated completed
2. Action
  Adopt and roll out the NHS Patient Safety Incident Review Framework for proportionate serious-incident investigations.
  Stated by Priory GroupStated in progress
3. Action
  Require full PSIRF investigations for absconding incidents from ward gardens or courtyards.
  Stated by Priory GroupStated completed
1. Action
  Provide updated serious-incident investigation training to all Hospital Directors.
  Stated by Priory GroupStated planned
2. Action
  Review incident reports and response actions through divisional Quality Improvement Leads, escalating concerns about inadequate action.
  Stated by Priory GroupStated in progress
AI-generated summary

Matthew Alexander CASEBY · 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

Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.

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 of serious incident investigations to identify and implement critical lessons
Wider context from the report
“4. Serious Incidents: The inquest heard evidence that a previous absconsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focussed on why the patient absconded to have a cigarette. I have serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time. ”
Source location
Matthew Alexander CASEBY · Prevention of Future Deaths report
Page 5 · 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
Amend 72-hour and team incident reports to document lessons learned and recurrence-prevention actions in greater detail.

Verbatim wording from the response
“72-Hour Reports: Priory has amended the 72-hour incident report and team incident reporting system to ensure that these document in more detail the lessons learnt from incidents and the actions taken to prevent a re-occurrence of such incidents.”

Source location
Response from Priory Group
Page 3 · response
Published 27 April 2022
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
Adopt and roll out the NHS Patient Safety Incident Review Framework for proportionate serious-incident investigations.

Verbatim wording from the response
“Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.”

Source location
Response from Priory Group
Page 3 · response
Published 27 April 2022
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
Require full PSIRF investigations for absconding incidents from ward gardens or courtyards.

Verbatim wording from the response
“Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.”

Source location
Response from Priory Group
Page 3 · response
Published 27 April 2022
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 updated serious-incident investigation training to all Hospital Directors.

Verbatim wording from the response
“Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.”

Source location
Response from Priory Group
Page 3 · response
Published 27 April 2022
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
Review incident reports and response actions through divisional Quality Improvement Leads, escalating concerns about inadequate action.

Verbatim wording from the response
“Monitoring: The following checks are being undertaken to ensure that there is an appropriate response to incidents:”

Source location
Response from Priory Group
Page 3 · response
Published 27 April 2022
Open published response
19 Apr2022
Surrey
Concerns raised2
1. Failure to declare serious incidents
2. Failure to investigate wider circumstances of serious incidents
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Volodymyr KOROL · 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

Volodymyr Korol died from a fatal ventricular arrhythmia in his bedroom at Shrewsbury Court Independent Hospital on 1 August 2020, following cardiac and other physical health conditions. The inquest identified concerns including failures to assess his capacity regarding weight management, investigate and manage cardiac and other physical health conditions, share medical information, and escalate abnormal vital signs. The Coroner was concerned that similar practices might be present at another site operated by Whitepost Healthcare Group.

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 declare serious incidents
Wider context from the report
“Following Mr Korol’s death Shrewsbury Court Independent Hospital did not declare a Serious Incident. As such, whilst there was a 72 hour serious incident review into the events of 31 July and 1 August 2020, there was no investigation into the wider circumstances leading up to his death. Accordingly, none of the matters which form part of the jury’s narrative conclusion were identified by Shrewsbury Court Independent Hospital either at the time as part of their own internal investigation or thereafter as part of their preparation for the inquest. The court heard evidence that Shrewsbury Court Independent Hospital has now closed down but that Whitepost Healthcare Group continues to operate one other site, namely Iden Manor Nursing Home in Kent. The jury found that there were a number of causative failures in relation to the carrying out of mental capacity assessments, the sharing of medical information with other agencies and the appropriate escalation of vital signs which fall outside of normal parameters. All of these issues are equally as important in nursing homes as they are in psychiatric hospitals. Given that these issues were not identified and acted upon by Whitepost Healthcare Group at any point prior to the inquest, the Coroner is concerned that similar practices may be present at Iden Manor Nursing Home in Kent, which would present a risk of future deaths. In the circumstances the Coroner considers that practices should be audited at Iden Manor Nursing Home to ensure that the deficient practices identified by the jury in relation to Mr Korol’s care at Shrewsbury Court Independent are not present at Iden Manor Nursing Home. ”
Source location
Volodymyr KOROL · Prevention of Future Deaths report
Page 7 · 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 investigate wider circumstances of serious incidents
Wider context from the report
“Following Mr Korol’s death Shrewsbury Court Independent Hospital did not declare a Serious Incident. As such, whilst there was a 72 hour serious incident review into the events of 31 July and 1 August 2020, there was no investigation into the wider circumstances leading up to his death. Accordingly, none of the matters which form part of the jury’s narrative conclusion were identified by Shrewsbury Court Independent Hospital either at the time as part of their own internal investigation or thereafter as part of their preparation for the inquest. The court heard evidence that Shrewsbury Court Independent Hospital has now closed down but that Whitepost Healthcare Group continues to operate one other site, namely Iden Manor Nursing Home in Kent. The jury found that there were a number of causative failures in relation to the carrying out of mental capacity assessments, the sharing of medical information with other agencies and the appropriate escalation of vital signs which fall outside of normal parameters. All of these issues are equally as important in nursing homes as they are in psychiatric hospitals. Given that these issues were not identified and acted upon by Whitepost Healthcare Group at any point prior to the inquest, the Coroner is concerned that similar practices may be present at Iden Manor Nursing Home in Kent, which would present a risk of future deaths. In the circumstances the Coroner considers that practices should be audited at Iden Manor Nursing Home to ensure that the deficient practices identified by the jury in relation to Mr Korol’s care at Shrewsbury Court Independent are not present at Iden Manor Nursing Home. ”
Source location
Volodymyr KOROL · Prevention of Future Deaths report
Page 7 · concerns
Open source report
11 Apr2022
Norfolk
Concerns raised2
1. Inaccuracies in patient safety incident investigation reports
2. Patient safety investigations omitting relevant incident and record-keeping concerns
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure review authors do not repeat the omission of relevant safety concerns in future reviews.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
AI-generated summary

Tracy Dawn WOOD · 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

Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

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
Inaccuracies in patient safety incident investigation reports
Wider context from the report
“11. The PSII Report contains many inaccuracies including Tracy’s date of death, stating it to be 5 June 2021. The report refers to Tracy ████████ again at 21:00 on 3rd June 2021. The correct date is the 2 June 2021 ”
Source location
Tracy Dawn WOOD · 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
Patient safety investigations omitting relevant incident and record-keeping concerns
Wider context from the report
“15. The PSII does not make findings with regard to areas of concern raised at the inquest such as with regard to Tracy being given a ████████ on the morning of 1 June 2021 despite there being a bold red note contained in the records that Tracy should not be given a ████████, that this was not discussed with any other senior member of staff, no record was made of the decision and the rationale for the decision, nor that the ████████ was not returned on Tracy’s return. The PSII does not include reference to inaccurate record keeping and full records of important events not being kept. ”
Source location
Tracy Dawn WOOD · 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
Ensure review authors do not repeat the omission of relevant safety concerns in future reviews.

Verbatim wording from the response
“It transpires the SBAR was a document not uploaded onto the electronic record. This led to the author not being aware of the SBAR and reporting on what was in the electronic record only, this was a gap in attention to detail. This aspect regarding the risk posed by the bandage should have been included in the review and was an omission, the author of the review has reflected on this and will ensure this is not repeated.”

Source location
Response from Hellesdon Hospital
Page 5 · response
Published 26 April 2022
Open published response
16 Mar2022
Manchester South
Concerns raised2
1. Flawed and limited review of serious clinical incidents
2. Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Billy Longshaw · 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

Billy Longshaw died at Stepping Hill Hospital on 7 March 2021 from complications of an undiagnosed sigmoid volvulus, following an earlier Emergency Department assessment at Great Western Hospital. He was allowed to leave without basic blood tests, a diagnosis, or serious abdominal pathology being fully excluded. Concerns included the lack of a detailed investigation by the Trust, flaws in its incident review, and the adequacy of education and practical understanding concerning the Mental Capacity Act 2005.

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
Flawed and limited review of serious clinical incidents
Wider context from the report
“2) The ’48 Hour Report for Significant incidents resulting in Moderate Harm and above’ prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust’s own medical records), prefaced as it is by the assumption that ‘the patient self-discharged against medical advice’. The Trust’s (limited) review of this matter represents a missed opportunity to consider vital issues such as the presentation of patients with significant learning disabilities to the Emergency Department, and the practical application of the Mental Capacity Act 2005 in this clinical setting. ”
Source location
Billy Longshaw · 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 undertake detailed, rigorous and effective investigations of serious clinical incidents
Wider context from the report
“1) Notwithstanding Mr Longshaw died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him. Prompt, rigorous and effective investigations into serious clinical incidents are essential to deriving learning and improving patient safety; ”
Source location
Billy Longshaw · Prevention of Future Deaths report
Page 3 · concerns
Open source report
10 Nov2021
County Durham and Darlington
Concerns raised1
1. Failure to undertake serious incident reviews of supervision failures
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Philip Anthony ELLIS · 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

Philip Anthony Ellis died on 28 May 2021 at a drugs rehabilitation service after self-administering drugs that he had obtained while leaving the premises unsupervised. The principal concerns were that he was able to leave the service in breach of its rules to obtain drugs, and that Free the Way had not undertaken a serious incident review into the supervision failures.

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 serious incident reviews of supervision failures
Wider context from the report
“That the deceased was able to leave the service premises unsupervised and obtain drugs in breach of the services own rules. The evidence at the Inquest indicated that there had not been a serious incident review undertaken by Free the Way into the failures of supervision in this case. ”
Source location
Philip Anthony ELLIS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
4 Oct2021
Manchester City
Concerns raised1
1. Factual errors and misinterpretations in SUI investigation reports
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
AI-generated summary

Jude Daryl Lloyd · 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

Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

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
Factual errors and misinterpretations in SUI investigation reports
Wider context from the report
“h. The GMMH SUI investigation report contained several factual errors and misinterpretations. The CMHT Responsible Clinician did not provide a statement or was interviewed despite him being a crucial witness. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”
Source location
Jude Daryl Lloyd · Prevention of Future Deaths report
Page 4 · 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
Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.

Verbatim wording from the response
“The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.”

Source location
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 6 · response
Published 13 October 2021
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
Assign a Patient Safety Practitioner to support and advise serious-incident review teams.

Verbatim wording from the response
“When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.”

Source location
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 6 · response
Published 13 October 2021
Open published response
27 Sep2021
Manchester City
Concerns raised2
1. Inaccurate and misinterpreted serious untoward incident investigation reports
2. Inadequate oversight of serious untoward incident investigation reports before sign-off
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
1. Action
  Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
AI-generated summary

Antony Declan Schofield · 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

Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent 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
Inaccurate and misinterpreted serious untoward incident investigation reports
Wider context from the report
“1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”
Source location
Antony Declan Schofield · 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
Inadequate oversight of serious untoward incident investigation reports before sign-off
Wider context from the report
“1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”
Source location
Antony Declan Schofield · 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
Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.

Verbatim wording from the response
“We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review. When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management. Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 5 · response
Published 5 October 2021
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
Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.

Verbatim wording from the response
“We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review. When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management. Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 5 · response
Published 5 October 2021
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
Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.

Verbatim wording from the response
“We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review. When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management. Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 5 · response
Published 5 October 2021
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
Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.

Verbatim wording from the response
“The report is then taken to a Post-Incident Executive Review Panel who can raise questions of the Review Authors and the Service Managers. Following any amendments, the Executive Panel approve the report and it’s content for release to the family and other concerned stakeholders, i.e. commissioners, coroners. It is expected that any factual inaccuracies are addressed during the review, the Trust have addressed this concern with the Author of the Trust’s RCA investigation in this case.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 5 · response
Published 5 October 2021
Open published response
24 May2021
Manchester West
Concerns raised1
1. Failure to trigger serious or untoward incident review following repeated falls
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

KENNETH SMITH · 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

Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

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 trigger serious or untoward incident review following repeated falls
Wider context from the report
“After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020. Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered. The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury. Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all. Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020. The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns: 1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful. 2. The failure to consider and specify a review date; 3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review. 4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority; ”
Source location
KENNETH SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 May2021
Manchester North
Concerns raised1
1. Deficient and ineffective Serious Incident Review process
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Liam Kenyon · 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

Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

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
Deficient and ineffective Serious Incident Review process
Wider context from the report
“7. Finally the Serious Incident Review process which is in place to learn lessons from such incidents was deficient and ineffective. ”
Source location
Liam Kenyon · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delayed and incomplete serious incident investigations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of serious incident investigations to identify and implement critical lessons

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised2

Failure to declare serious incidents

Failure to investigate wider circumstances of serious incidents

Concerns raised2

Inaccuracies in patient safety incident investigation reports

Patient safety investigations omitting relevant incident and record-keeping concerns

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Flawed and limited review of serious clinical incidents

Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents

Concerns raised1

Failure to undertake serious incident reviews of supervision failures

Concerns raised1

Factual errors and misinterpretations in SUI investigation reports

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Inaccurate and misinterpreted serious untoward incident investigation reports

Inadequate oversight of serious untoward incident investigation reports before sign-off

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Actions described in response 5

Respondent positions 1

Actions described in response 5

Actions described in response 1

Actions described in response 2

Actions described in response 4