Recurring concern

Unreliable preservation and disclosure of material for death investigations

First to latest report 6 Mar 2015 — 24 Mar 2026

Reports that mention this concern
21
Times this concern has been raised
23
Stated actions linked to this concern
25

What this concern includes

Includes failures in arrangements for gathering, retaining, preserving, reviewing, identifying and disclosing material relevant to death investigations, including local prison systems and material needed by coroners, courts, investigators or safety-learning functions.

What is not included
  • Excludes ordinary clinical or operational record-keeping failures where the material is not relevant to investigating a death.
  • Excludes failures in the underlying care, incident investigation or post-mortem process when preservation or disclosure of death-investigation material is not itself deficient.
  • Excludes general inquest disclosure failures concerning non-death-specific evidence or procedural information where no wider death-investigation material condition is supported.
  • Excludes failures to implement safety actions or learning after relevant death-investigation material has been reliably preserved, reviewed and disclosed.

Reports and published responses 21 reports

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

  1. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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 supplying material information relevant to death investigations and future-death prevention

    Wider context from the report

    “Concern 12: Failure of state agencies to supply all information in a timely fashion. In this Inquest I was presented with material information at the eleventh hour. Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed. ”

    Source location

    Ronald William MEIKLE · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Devon, Plymouth and Torbay

    AI-generated summary

    Lee Kenneth Eustace · 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

    Lee Kenneth Eustace was admitted for treatment of oesophageal cancer and underwent a gastro-oesophagectomy with jejunostomy feeding. He developed abdominal pain, but the feed was increased and continued, and he subsequently developed jejunostomy feeding syndrome and bowel ischaemia, dying in intensive care on 1 May 2022. The report raises concerns about an insufficient and partly un followed feeding protocol, and about failures to investigate the incident, comply with the Duty of Candour, and provide relevant information to the Coroner.

    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 provide relevant documentation to the Coroner under Schedule 5 disclosure duties

    Wider context from the report

    “I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirement to do so under Datix. I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths. ”

    Source location

    Lee Kenneth Eustace · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. North Yorkshire and York

    AI-generated summary

    Malik BUNTON · 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

    Malik Bunton was found suspended from a ligature on 17 July 2023, and his death was confirmed at the scene. The inquest concluded that he died as a result of suicide, following earlier incidents involving suicidal intent and self-harm concerns. The principal concerns related to insufficient inquiry into an earlier incident, weaknesses in the Defence Medical Service Clinical Care Review process, and delays or obstructions in gathering important 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

    Failure to preserve potentially important service email evidence

    Wider context from the report

    “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were – - The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process. - The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest. - The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide. - Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death. - The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned. ”

    Source location

    Malik BUNTON · 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

    Implement a process to retain, where appropriate, deceased service personnel’s email accounts for potential inquest evidence retrieval.

    Verbatim wording from the response

    “Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.”

    Source location

    Response from Ministry of Defence
    Page 2 · response
    Published 20 October 2025

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Anthony Binfield and 2 others · 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

    Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous 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

    Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material

    Wider context from the report

    “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place. ”

    Source location

    Anthony Binfield and 2 others · 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

    Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.

    Verbatim wording from the response

    “More generally HMPPS is committed to learning from all deaths and to taking action to address any issues that are identified as a result. The Follow-up to Deaths in Custody policy framework describes the early learning review process for all apparently non-natural deaths, through which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the National Safety Group. It also explains our commitment to supporting the various independent investigations processes that follow a death and particularly to meeting our duty of candour, including by disclosing all relevant documents.”

    Source location

    Response from HMPPS
    Page 7 · response
    Published 13 February 2025

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    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

    Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.

    Verbatim wording from the response

    “I am sorry that there were delays in the disclosure of material during these inquests. We have reviewed the handling of the inquests with Government Legal Department (GLD) and we believe that this was the result of the unusual circumstances of this case, which had a broad scope that reached into areas not commonly subject to such investigation. The Follow-up to Deaths in Custody policy framework sets out very clearly the requirement to retain documents relevant to the death and specifically notes that there may be a considerable delay between the death and the inquest, and that the coroner may ask for documentation not requested by either the police or the PPO, pointing out that it is therefore crucial that prisons retain all documentation available. In the vast majority of cases prisons are complying with this guidance and it is proving sufficient to meet the needs of coroners.”

    Source location

    Response from HMPPS
    Page 8 · response
    Published 13 February 2025

    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

    Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.

    Verbatim wording from the response

    “Whilst Sodexo always considers early admissions and agreed facts, the unique circumstances of these cases, with the number of overlapping organisations involved and individual officers with separate IP status, as well as ongoing and late disclosure of relevant material by the Ministry of Justice, meant that admissions by Sodexo, without trespassing on factual evidence due to be heard at the inquest involving other IPs, was more difficult and complex than would usually be the case. There are three further inquests involving Sodexo concerning deaths at HMP Lowdham Grange, and Sodexo will give careful consideration to admissions and agreement of facts in relation to each.”

    Source location

    Response from Sodexo
    Page 3 · response
    Published 13 February 2025

    Open published response

  5. Inner West London

    AI-generated summary

    Elton Deutekom · 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

    Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.

    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 disclose evidence relevant to deaths to the coroner under the duty of candor

    Wider context from the report

    “2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public, which thus raises the same concern as above. ”

    Source location

    Elton Deutekom · 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

    Review internal legal and governance processes to maintain clear records of disclosure.

    Verbatim wording from the response

    “The Trust is reviewing its internal legal and governance processes to ensure clear records of disclosure are maintained so that we may provide assurance should the need arise in future.”

    Source location

    Response from Chelsea and Westminster NHS Foundation Trust
    Page 4 · response
    Published 3 December 2024

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    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 response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.

    Verbatim wording from the response

    “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 3 December 2024

    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

    Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.

    Verbatim wording from the response

    “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 3 December 2024

    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

    The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.

    Verbatim wording from the response

    “It is denied that the court was not provided with the evidence it required when requested. As set out below, the Trust has confirmed that disclosure was made at the times requested prior to inquest, on 16 May 2023. Emails confirming this fact are enclosed for the attention of the Coroner. Despite this, the Trust appreciates that there were difficulties in establishing what had been disclosed and when during the hearing, and has fed this back internally.”

    Source location

    Response from Chelsea and Westminster NHS Foundation Trust
    Page 4 · response
    Published 3 December 2024

    Open published response

  6. East London

    AI-generated summary

    Terence Harry Clark · 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

    Terence Harry Clark, who had an impaired swallow and aspiration pneumonia, was admitted to hospital on 26 October 2023 and died there on 1 November 2023 after sustaining a cardiac arrest while waiting unescorted in an X-ray waiting area. Concerns included the discovery of liquid food in his airway, the unexplained removal and loss of his naso-gastric tube, and the failure to identify the tube’s removal as a significant factor during the patient safety investigation, which impeded investigation of the death.

    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 secure and document clinical apparatus relevant to investigations

    Wider context from the report

    “A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark’s airway at autopsy. The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death. ”

    Source location

    Terence Harry Clark · 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

    Review and update the Bereavement policy to clarify when tubes, lines and devices remain in situ after sudden or unexpected death, including medical examiner involvement.

    Verbatim wording from the response

    “Following this case, we are reviewing the Bereavement policy to clarify the guidance around removal of tubes, lines and devices. Where a sudden or unexpected death has occurred, the policy will mandate that tubes, lines and devices are left in situ until after:”

    Source location

    Response from Barts Health
    Page 2 · response
    Published 2 September 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

    Discuss the removal guidance at safety huddles with senior nursing and site teams to reinforce a lower threshold for coroners’ office discussion.

    Verbatim wording from the response

    “This case has already been discussed at our safety huddles, with the senior nursing and site teams to underline the above and ensure a lower threshold for discussion with the coroners office should there be any doubt about removal of lines etc. Any conversation will be documented in the patient record. We will be cascading the learning from this incident and embedding this within training across the Trust.”

    Source location

    Response from Barts Health
    Page 3 · response
    Published 2 September 2024

    Open published response

  7. Northumberland

    AI-generated summary

    Elise Walsh Deceased · 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

    Elise Walsh had a history of self-harm and suicidal ideation and suffered a severe hypoxic brain injury after an incident in hospital on 12 February 2022. She later developed aspiration pneumonia and died on 7 June 2023. Concerns included a significant note of intent not being made available earlier and complaint forms potentially being handled in a way that could cause important patient information to be missed or delay treatment or intervention.

    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 make significant patient information available promptly

    Wider context from the report

    “1. The deceased attended an appointment at St George’s Park Hospital on the 12 February 2022. After the appointment she was waiting for a taxi, walking up and down the corridor and appeared to be getting more agitated. She was not happy with how her appointment went and voiced those concerns verbally. When the taxi arrived, she refused to get in and the taxi left. She remained at reception where she voiced her anger at the Crisis Team and requested a Complaints Form. I describe it as a note of intent and do not repeat its content. It is not referred to in any witness statements, it is not referred to in the Serious Incident Investigation. I had it was discussed at the After Action Review but it has not made its way through to the Serious Incident Investigation. It was disclosed to my office on Friday 16 August 2024 and of greater concern the family were not aware of its existence. I am concerned this significant information was not made available much earlier. ”

    Source location

    Elise Walsh Deceased · 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

    Redesign incident review templates to carry identified issues and key enquiry lines into full patient safety investigations.

    Verbatim wording from the response

    “The Trust now carry out internal investigations in accordance with PSIRF (Patient Safety Incident Response Framework). In line with PSIRF CNTW's review templates have been redesigned to ensure that identified issues/key lines of enquiry are carried forward and are not lost when a review progresses to a full Patient Safety Incident Investigation. Following on from the Inquest the Head of Clinical Risk and Investigations has spoken with the Trust's dedicated Investigating Officers to remind them that whenever an issue is raised as part of discussion during an incident review process it is then explored further and addressed in the completed report.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 1 · response
    Published 30 August 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

    Remind dedicated investigating officers to investigate and address issues raised during incident reviews in completed reports.

    Verbatim wording from the response

    “The Trust now carry out internal investigations in accordance with PSIRF (Patient Safety Incident Response Framework). In line with PSIRF CNTW's review templates have been redesigned to ensure that identified issues/key lines of enquiry are carried forward and are not lost when a review progresses to a full Patient Safety Incident Investigation. Following on from the Inquest the Head of Clinical Risk and Investigations has spoken with the Trust's dedicated Investigating Officers to remind them that whenever an issue is raised as part of discussion during an incident review process it is then explored further and addressed in the completed report.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 1 · response
    Published 30 August 2024

    Open published response

  8. Nottinghamshire

    AI-generated summary

    Kevin John McDonnell · 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

    Kevin John McDonnell was discovered deceased in his prison cell on 29 September 2022, having died by ligature asphyxiation; the inquest concluded that he had died by suicide. The principal concerns included failures to conduct planned ACCT reviews and checks, share identified suicide-risk information, provide necessary mental-health support, and preserve accurate documentary evidence after his death.

    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 secure and retain accurate documentary evidence following a death in custody

    Wider context from the report

    “3. Failure to secure and retain documentary evidence following a death in custody. If post-death investigations are misled by inaccurate documentation that has been amended post-death, then the ability to learn from deaths in custody will be hampered. The preservation of accurate documentary evidence must be of paramount concern when a person dies in custody. ”

    Source location

    Kevin John McDonnell · 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

    Keep ACCT books on the wing during quality assurance checks so staff can make contemporaneous entries.

    Verbatim wording from the response

    “The matter of accurate documentary evidence being secured following a death in custody is something that I take extremely seriously. I am satisfied that the actions taken by staff in this instance were not malicious or done with the intention of misleading any investigation or enquiry. Nevertheless, this was not best practice and I understand that ACCT books are no longer taken”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 9 August 2024

    Open published response

  9. Nottinghamshire

    AI-generated summary

    Christopher Howard 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

    Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

    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 identifying and supplying material relevant to inquests

    Wider context from the report

    “2. An inability to record, retain and supply HM Coroner with material relevant to the inquest The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing. Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time. The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths. An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division. ”

    Source location

    Christopher Howard SMITH · 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

    Implement a core-information checklist and weekly senior oversight of post-incident information collation and storage.

    Verbatim wording from the response

    “It is with deep regret that we were not able to supply you with the relevant materials to support the Coronial process. We recognise the impact this had on your investigation but also the distress to the family, which is not acceptable. We are committed to improving this process across the Trust to ensure you and your team are provided with all relevant information to support your enquiries, and that there is support for Clinical Teams post serious incident, including where a death has occurred.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 6 November 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

    Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.

    Verbatim wording from the response

    “The Medico Legal Team and senior managers now hold a weekly Inquest Oversight Meeting whereby the specific requirements of each case are reviewed and updated to ensure documents and staff members required are identified and located at an earlier stage of the process. Discussions are held in terms of any witness conflict concerns, noting the important learning that came from Mr Smith’s inquest in this regard. In addition, any staff members not engaging with the process are identified and this is escalated appropriately, with clear guidance that the Trust cannot represent staff members who do not engage with the Trust support in terms of statement provision and preparation for the inquest itself.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 4 · response
    Published 6 November 2023

    Open published response

  10. Avon

    AI-generated summary

    Celia Lindsey MARSH · 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

    Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.

    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 obtain and preserve stomach contents and tissue samples at post-mortem examination

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · 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 hospital blood samples in suspected anaphylaxis cases

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · 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

    Establishing the systems identified by the Coroner falls outside UKHSA’s remit.

    Verbatim wording from the response

    “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.”

    Source location

    Response UK Health Security Agency
    Page 1 · response
    Published 25 November 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

    Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.

    Verbatim wording from the response

    “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.”

    Source location

    Response from Food Standards Agency
    Page 3 · response
    Published 25 November 2022

    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