Recurring concern
Unreliable preservation and disclosure of material for death investigations
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Request correctionFirst reported 6 Mar 2015•Latest report 24 Mar 2026
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.
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
- 21
- Individual concerns
- 23
- Date range
- 2015–2026
- Stated actions
- 25
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised1
Delays in supplying material information relevant to death investigations and future-death prevention
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide relevant documentation to the Coroner under Schedule 5 disclosure duties
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to preserve potentially important service email evidence
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement a process to retain, where appropriate, deceased service personnel’s email accounts for potential inquest evidence retrieval.
Stated by Ministry of Defence
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Concerns raised1
Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.
Stated by HM Prison and Probation Service
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Position
Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
Stated by Sodexo
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Concerns raised1
Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review internal legal and governance processes to maintain clear records of disclosure.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
Stated by NHS England
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Position
Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
Stated by NHS England -
Position
The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
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Concerns raised1
Failure to secure and document clinical apparatus relevant to investigations
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
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.
Stated by Barts Health NHS Trust -
Action
Discuss the removal guidance at safety huddles with senior nursing and site teams to reinforce a lower threshold for coroners’ office discussion.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to make significant patient information available promptly
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Redesign incident review templates to carry identified issues and key enquiry lines into full patient safety investigations.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust -
Action
Remind dedicated investigating officers to investigate and address issues raised during incident reviews in completed reports.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Concerns raised1
Failure to secure and retain accurate documentary evidence following a death in custody
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Keep ACCT books on the wing during quality assurance checks so staff can make contemporaneous entries.
Stated by HM Prison and Probation Service
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Concerns raised1
Delays in identifying and supplying material relevant to inquests
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement a core-information checklist and weekly senior oversight of post-incident information collation and storage.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised2
Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination
Failure to retain hospital blood samples in suspected anaphylaxis cases
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Stated by UK Health Security Agency
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Position
Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Stated by Food Standards Agency
Data last updated 7 September 2026