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. Avon

    AI-generated summary

    Lesley Julie BRASS · 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

    Lesley Julie BRASS fell at home, sustained a head injury, and was admitted to hospital after her wound became infected. While an inpatient, she developed severe hyperkalaemia but did not receive the required emergency treatment within the specified timeframe, and she suffered a fatal cardiac arrest. The report raises concerns about failures to recognise, escalate and treat the condition, and about the Plastic Surgery department’s subsequent investigation, openness and willingness to acknowledge mistakes.

    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 the Plastic Surgery department to properly investigate serious untoward incidents

    Wider context from the report

    “During the course of the pre-inquest investigation, and at the inquest itself, evidence came to light which led me to conclude that the Trust in general, and the Plastic Surgery department in particular, was/were reluctant to investigate Mrs Brass’s death properly, and to be open about their findings. I am particularly concerned that a number of the consultants from the Plastic Surgery department failed to co-operate with and/or progress the investigation. ”

    Source location

    Lesley Julie BRASS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Wayne Lee Millett · 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

    Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.

    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 critically analyse care and treatment against the Care Plan

    Wider context from the report

    “1) The Priory’s own investigation into the circumstances of Mr Millett’s death was notably lacking in meaningful critical analysis of the care and treatment he received, and in particular was fundamentally flawed in that it failed to consider the care given as against the Care Plan despite its obvious central relevance to his death. ”

    Source location

    Wayne Lee Millett · 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

    Lack of overarching quality assurance for serious incident investigations

    Wider context from the report

    “2) The above concern, when taken in conjunction with the facts that: a) the evidence before the court confirmed the organisation’s Director of Risk Management, ████████ had input into the investigation; and b) the Peripatetic Director of Clinical Services who gave evidence before the court was unable to describe any overarching quality assurance process operating within the organisation in respect of serious incident investigations; This raises significant concerns as to the Priory Group’s ability to learn from serious clinical incidents and to take action accordingly, thus creating a risk of future deaths. ”

    Source location

    Wayne Lee Millett · 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

    Recruit a serious incidents investigation officer with a mandate to improve investigation processes.

    Verbatim wording from the response

    “In relation to your concern that we are not a learning organisation, please note we continue to invest significant time and resource in making continuous improvements to the services we provide to some of the most clinically challenging mental health patients in the UK. This includes in relation to incident investigations: in March this year we recruited a highly-experienced serious incidents investigation officer (SIO) with a clear mandate to make improvements to our processes for the benefit of patients and staff including:”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 1 · response
    Published 26 February 2020

    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

    Deliver investigation and report-writing training to senior staff conducting serious incident investigations.

    Verbatim wording from the response

    “• Delivering training to senior staff who are commissioned to complete investigations and prepare reports to ensure they have the necessary skills to identify key issues and convey those concisely and clearly in their written outputs;”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 2 · response
    Published 26 February 2020

    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 senior staff, including the Group Medical Director and Director of Quality, to review every draft serious incident investigation report.

    Verbatim wording from the response

    “• Strengthening the review process so that all draft serious incident investigation reports are reviewed by a team of senior staff which in all cases includes the Group Medical Director and the Director of Quality.”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 2 · response
    Published 26 February 2020

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Andrew Peter Wells · 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

    Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.

    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

    Lack of robust and effective root cause analysis of serious incidents

    Wider context from the report

    “1. The Trust’s Internal Root Cause Analysis investigation reviewed the decision making of the clinicians including the role of the treating consultant psychiatrist, the unit’s Responsible Clinician. However, on one on the investigation team was a psychiatrist, or of a similar status to the Responsible Clinician. The RCA report agreed with the Responsible Clinician that the decision making around Mr Wells’ informal status and observation levels was appropriate. The draft RCA report went through a governance exercise, and a member happened to be a consultant psychiatrist, but this did not involve scrutiny of the evidence. I agreed with the evidence from an independent expert consultant psychiatrist that the decision making of the clinicians, including the Responsible Clinician, was not appropriate. Therefore, my on-going concern is that the Trust’s RCA process is not robust or effective enough to learn lessons from serious incidents. ”

    Source location

    Andrew Peter Wells · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Bedfordshire and Luton

    AI-generated summary

    Pamela Evans · 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

    Pamela Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s 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 of serious incident investigations to detect significant safety concerns and learning

    Wider context from the report

    “(v)       That points (i)-(iv) had not been detected by the Trust despite its carrying out of a serious incident investigation. I am therefore concerned that significant and potentially life-saving learning may be missed by the Trust in the future even if serious incident investigations are carried out. ”

    Source location

    Pamela Evans · 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 serious incident investigation considered relevant actions and decision-making and did not fall short of its intended purpose.

    Verbatim wording from the response

    “Hospital SI report did not acknowledge or highlight these issues Thank you for drawing my attention to these issues. As you know a serious incident report is to ensure gaps in care, root causes and learning are identified in order to protect future patients and improve our practice.”

    Source location

    2019-0333-Response-by-Bedford-Hospital-NHS-Trust
    Page 3 · response
    Published 10 November 2019

    Open published response

  5. Blackpool and the Fylde

    AI-generated summary

    James David FLETCHER · 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

    James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

    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 internal serious incident investigations to identify PEG contraindications

    Wider context from the report

    “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation. ”

    Source location

    James David FLETCHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Malcolm John Rathmell · 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

    Malcolm Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future 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 establish how or why the anticoagulation chart was mislabelled

    Wider context from the report

    “(3) It has not been possible to establish how or why this happened despite an extensive investigation by the Trust and a detailed enquiry during the inquest. ”

    Source location

    Malcolm John Rathmell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Norfolk

    AI-generated summary

    RUTH PATRICIA WHITMORE · 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

    Ruth Patricia Whitmore, who had multiple comorbidities, sustained a large haematoma when her leg became caught in a bed rail during hospital care on 7 January 2018. Her condition deteriorated after community care and readmission, and she died on 13 April 2018; concerns included inadequate handover of responsibility and an initial investigation that was not robust or sufficiently thorough.

    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 conduct robust and thorough incident investigations

    Wider context from the report

    “(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient. No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events. It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough. ”

    Source location

    RUTH PATRICIA WHITMORE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Staffordshire South

    AI-generated summary

    Thomas Paul Arthur JACKSON · 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

    Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

    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 serious incident reviews affecting process validity

    Wider context from the report

    “(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Surrey

    AI-generated summary

    Rita Taylor · 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

    Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

    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 the serious incident report to fulfil its learning and accuracy obligations

    Wider context from the report

    “7. As was acknowledged in Court, the SI report did not fulfil its obligations and it was agreed that it would be extensively re-written and re-presented to HM Coroner’s Court to more accurately reflect the circumstances of Mrs Taylor’s death and the learning points required to assist in preventing any future deaths. ”

    Source location

    Rita Taylor · 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

    Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.

    Verbatim wording from the response

    “Response - ████████ Associate Medical Director and Responsible Officer, gave evidence in court that the Trust would be reviewing the concerns raised during the inquest process and that we would be preparing a supplemental Root Cause Analysis ‘RCA’ report to address these concerns. A copy of the supplemental RCA report is enclosed and we hope that you agree that the actions and recommendations set out within the Action Plan of this report address the concerns raised within your Report to Prevent Future Deaths.”

    Source location

    2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 4 · response
    Published 23 September 2018

    Open published response

  10. North Wales (East and Central)

    AI-generated summary

    Neville Welton · 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

    Neville Welton attended Wrexham Maelor Hospital on the evening of 12 December 2017 after referral by his GP. Delays in assessment and treatment, associated with capacity and patient flow problems, staffing issues, and administrative and escalation failures, were followed by deterioration and his death in the early hours of the next morning. Concerns included the delay in completing the Health Board’s investigation and action plan, missed implementation timescales, and wider delays in completing serious incident reviews and action plans.

    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 concluding serious incident investigations and reviews

    Wider context from the report

    “The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death. I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time. Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans. ”

    Source location

    Neville Welton · Prevention of Future Deaths report
    Page 1 · 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 serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.

    Verbatim wording from the response

    “Moving forward In terms of moving forward a number of actions are being implemented to improve the timeliness of our processes and the development of the action plans:”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 2 · response
    Published 8 July 2018

    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

    Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.

    Verbatim wording from the response

    “2. The Health Board is to introduce a weekly Incident Review Meeting (Scoping document Appendix 1) to review on a regular basis all incidents reported on Datix in the previous 7 days. The meeting will be chaired by the Associate Director of Quality Assurance and attended by the senior staff with a specific responsibility for quality and patient safety from each division.”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 3 · response
    Published 8 July 2018

    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 a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.

    Verbatim wording from the response

    “3. A project management approach to be used when conducting a comprehensive investigation with milestones for completion signed up to by the designated Chair (see appendix 2). This approach is not yet in place and will be implemented as part of the revised model described above.”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 3 · response
    Published 8 July 2018

    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

    Legal advice was required before the investigation report could be signed off, delaying completion.

    Verbatim wording from the response

    “• Legal advice in relation to breach of duty, qualifying liability and causation was required and it was assessed that the report could not be signed off by the Chair until this was received.”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 2 · response
    Published 8 July 2018

    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