Recurring concern

Unreliable preservation and disclosure of material for death investigations

Pin Get email alerts Request correction

First reported 6 Mar 2015•Latest report 24 Mar 2026

Definition

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

Distinct published reports

Individual concerns
23

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
25

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.

Department of Health and Social Care3
HM Prison and Probation Service3
NHS England3
Central and North West London NHS Foundation Trust2
Lowdham Grange Prison2
Ministry of Justice2
Nottinghamshire Healthcare NHS Foundation Trust2
Pentonville Prison2
Woodhill Prison2
Barts Health NHS Trust1
British Retail Consortium1
Care Quality Commission1
Care UK1
Chelsea and Westminster Hospital1
Chelsea and Westminster Hospital NHS Foundation Trust1

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.

  1. Inner North London

    AI-generated summary

    Roy Elton TRAVERS · 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

    Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.

    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 disclosing relevant review information to HM Coroner

    Wider context from the report

    “5. As you will be aware, an ancillary function of every inquest is to attempt to learn lessons from the death, the driver behind prevention of future deaths reports. However, it is incumbent upon every hospital trust to consider the deaths of those within its care long before the matter comes to inquest, and to attempt to learn from these if possible. Whittington Health conducted a 72 hour review of Mr Travers’ care on 17 June 2022. This was disclosed to my coroner’s officer late on the afternoon of Friday, 4 November, in preparation for an inquest listed for 10am on Monday, 7 November. This meant that Mr Travers’ family and I received the 72 hour review on the morning of inquest. This had several consequences. • It placed family members in an unfair position in terms of their preparation for inquest. • It did not comply with the duty to co-operate with HM Coroner, not simply when asked but also by volunteering all relevant information. • It denied HMC the ability to call to inquest any witnesses the need for whom only became apparent from the review. • And it did not inspire confidence that Whittington Health took its own review seriously and tried to learn from it. Even the Whittington consultant giving oral evidence at inquest only saw the review on the morning of inquest, and then purely as a result of being provided it by my coroner’s officer. ”

    Source location

    Roy Elton TRAVERS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Swansea and Neath Port Talbot

    AI-generated summary

    Robert Lee 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

    Robert Lee Evans, a prisoner at HMP Swansea, was found deceased in his cell in the early hours of 14 January 2018 after tying a ligature around his neck, shortly after arriving at the prison and while undergoing alcohol detoxification. The concerns included inadequate assessment and monitoring of his suicide and self-harm risk, failures relating to prescribed antidepressant and detoxification medication, and failures to promptly capture evidence from prison staff witnesses 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 promptly capture and consider evidence relevant to deaths in custody

    Wider context from the report

    “I heard evidence from the two prison officers who appear in the HMP Swansea CCTV as mentioned above. On the evidence I have seen these witnesses were the last members of prison staff Lee spoke to before his death. At all stages into the investigation into Lee’s death (prisons and probations ombudsman and coronial) these witnesses have stated that they are unable to assist with what Lee was saying to them before his death. I am concerned that immediately following Lee’s death and the following day that these highly material witnesses (who were on duty) were not spoken to, did not attend a hot or cold debrief and were not asked to make a first account of events when matters were fresh in their minds. These witnesses did become known to the PPO. As a result, my investigation into Lee’s death has been significantly hampered. I am therefore concerned that lessons may not have been fully learnt from the circumstances of Lee’s death. I am concerned that if evidence relevant to a death in custody is not immediately captured and considered a situation may be created where evidence is lost which prevents general lessons from being learnt from a death in custody and that this creates a risk that other deaths will occur. ”

    Source location

    Robert Lee Evans · 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

    Draft and update the death-in-custody policy framework to identify relevant staff and prompt early recording of their information.

    Verbatim wording from the response

    “I recognise the importance of ensuring that any evidence relating to deaths in custody is preserved, including the recollections of staff who have had recent interactions with the deceased individual. Prisons are required to have contingency plans in place that include debriefs with staff who were on the scene at the time of the incident, but these will not be the only staff to have had potentially relevant contact with the prisoner. We are currently drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, and within this will include guidance for prisons to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage.”

    Source location

    Response from HM Prision and Probabtion Services
    Page 2 · response
    Published 20 October 2022

    Open published response

  3. Nottinghamshire

    AI-generated summary

    NIGEL JOHN SAUNDERS · 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

    Nigel John Saunders was detained at HMP Lowdham Grange and was found suspended by ligature on 17 November 2018. He was pronounced deceased in hospital on 18 November 2018 following hypoxic brain injury sustained during the suspension. The concerns included failings in his admission to the Segregation Unit, care under the ACCT Plan, and searching before entering the shower area, as well as failures to retain and preserve evidence relevant to investigations of deaths in custody.

    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

    Insufficient robustness of the local system for retaining and preserving material relevant to deaths

    Wider context from the report

    “(1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learn from deaths in custody. (2) The local system in place for the retention and preservation of material likely to be relevant to the circumstances of death is not as robust as it ought to be. This is not the first time serious disclosure irregularities have undermined the veracity of an Article 2 inquest involving this prison in my corner Area. I consider this to be a local issue of significant importance. If the investigations following a death are repeatedly hindered in their full and frank examination of the facts due to missed opportunities by the prison to have retained and preserved evidence, then lessons cannot be learned, and the risk of further deaths shall persist. The Chief Coroner highlights this specific area of risk at paragraph 42 of the revised Guidance Note 5. ”

    Source location

    NIGEL JOHN SAUNDERS · 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

    Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.

    Verbatim wording from the response

    “Following this inquest, the DSOP, including the DIC checklist has been reviewed further and an updated version is to be rolled out to the English Serco prison estate by the end of October 2022. The updated version of the DSOP will include a statement that the DIC Checklist is not an exhaustive list, and the Prison should retain any other document that it considers could be of relevance. The updated DSOP will be rolled out across the prison estate and guidance will be given to all staff responsible for collating relevant documentation following a death in custody. I understand that a copy of the DIC checklist that was in place at the time of Mr Saunders’ death and a copy of the DIC checklist, as amended in January 2021 were provided to you during the course of the inquest.”

    Source location

    Response from HMP Lowdham Grange
    Page 2 · response
    Published 7 October 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

    Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.

    Verbatim wording from the response

    “Over the years the Journal has been replaced by incident reports, which are completed and then reported to and discussed by the Director and the Senior Management Team on a daily basis. It is accepted that Journal entries may have contained relevant information following a DIC and consequently should have been included on the DIC checklist to ensure their preservation following a death. The Journal is now listed in the checklist, to ensure it is produced in Serco prisons that use an Oscars journal.”

    Source location

    Response from HMP Lowdham Grange
    Page 2 · response
    Published 7 October 2022

    Open published response

  4. Surrey

    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

    Failure to preserve the scene and fully inform police and coronial investigators after a death

    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

    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 position was interpreted

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

    PFD Monitor interpretation

    The police were informed of the cot bumper’s position and the relevant timing and circumstances of death were recorded in investigative materials.

    Verbatim wording from the response

    “Information provided to the police and coroner’s service We willingly complied with all external investigations that took place and also carried out our own detailed review. The evidence before the coroner at the inquest was that the police officer attending the scene following Connor’s death had been informed of the position in which the cot bumper had been found. This was reflected in the contemporaneous notes taken by the officer in their police-issued pocket notebook. The officer in question gave evidence at the inquest that he had been informed of the positioning of the bumper.”

    Source location

    Response from The Children's Trust
    Page 7 · 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

    Connor’s equipment and room remained sealed after staff repositioned him for clinical assessment, contrary to the concern that the scene was not preserved.

    Verbatim wording from the response

    “airway, check for breathing, and check circulation. Accordingly, when our staff first found Connor unresponsive in his cot, they moved him into a horizontal, supine position in order to assess his vital signs. The police then performed their own independent physical examination. All of Connor’s equipment remained in the room with him, and the room (including the bed and bumpers) remained sealed until the findings of the post-mortem were released.”

    Source location

    Response from The Children's Trust
    Page 8 · response
    Published 17 May 2022

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Quinn Lias Parker · 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

    Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.

    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 retain the placenta for full paediatric post mortem examination before coronial reporting

    Wider context from the report

    “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. 2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. 3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction. ”

    Source location

    Quinn Lias Parker · 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

    Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.

    Verbatim wording from the response

    “Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected.”

    Source location

    Response from NUH (3)
    Page 2 · response
    Published 6 October 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 whether placental examination processes need adaptation after receiving further information about the examination.

    Verbatim wording from the response

    “In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes.”

    Source location

    Response from NUH
    Page 2 · response
    Published 6 October 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

    The Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.

    Verbatim wording from the response

    “After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach.”

    Source location

    Response from NUH (3)
    Page 2 · response
    Published 6 October 2022

    Open published response

  6. Inner North London

    AI-generated summary

    Freeda GLAUSIUSZ · 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

    Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.

    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 prompt and candid cooperation with coronial inquiries

    Wider context from the report

    “2. I heard at inquest that the clinician and his manager had listened to the recording of the call within days of the death and had recognised very significant shortcomings. However, the recording was not volunteered to my coroner’s officer. I was aware of the existence of the call only because ████████ told my officer about it. • I received a copy of the recording of the call (without a transcript) the day before the inquest. • I received a statement from the clinician who took the call the day before the inquest. • I received statements from other ELFT clinicians in dribs and drabs earlier this month. • I received a copy of the SI report the day before the inquest. • I never received a copy of the 48 hour hot de-brief. • Freeda Glausiusz died five months ago. My officer first requested witness statements and a copy of any internal investigation on 7 June, over four months ago, and asked for the statements to be provided by 20 August. This chronology does not demonstrate an eagerness to promote a learning culture by ELFT. The failure to provide prompt and candid co-operation with my office obstructs the coronial inquiry, an inquiry that includes the function of learning from deaths. And it does not demonstrate respect for the family of the deceased. ”

    Source location

    Freeda GLAUSIUSZ · 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

    Employ four additional Serious Incident investigators to increase investigation capacity and address the backlog.

    Verbatim wording from the response

    “The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 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

    Clear the accumulated Serious Incident report backlog by the end of 2021.

    Verbatim wording from the response

    “The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 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

    Prioritise Serious Incident investigations with inquest dates and provide realistic due dates for late reports.

    Verbatim wording from the response

    “I have sought assurance from the Associate Director of Governance and Risk that until that time, SI investigations with inquest dates will be prioritised and that HM Coroner is provided with realistic due dates if SI reports are going to be submitted to the Coroner’s Court late.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide the Coroner with the 48-hour report when Serious Incident reports are late.

    Verbatim wording from the response

    “Additionally, in the instance that SI reports are late, HM Coroner will be provided with the 48 Hour report.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 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

    Hire an additional solicitor to increase Legal Affairs Team capacity by late March.

    Verbatim wording from the response

    “The Trust has also agreed to hire an additional solicitor in order to increase the Legal Affairs Team’s capacity which has been affected by long term sickness absence and the increase in inquests. A new solicitor will join the team by late March.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 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

    Chase witness statements and evidence promptly and provide realistic deadlines when delays affect progress.

    Verbatim wording from the response

    “In the interim, the Interim Associate Director of Legal Affairs has assured me the Legal Affairs Team will be tasked with diligently chasing up witness statements and evidence such as recordings in a timely manner and provide realistic deadlines to the Coroner’s Officers if issues such as clinician sick leave hinder progress.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 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

    Liaise with the Coroner’s Officer to discuss providing transcripts of recorded calls.

    Verbatim wording from the response

    “I note, the Trust has not previously been requested to provide transcripts of recordings of calls. Going forward, the Interim Associate Director of Legal Affairs will liaise with your Coroner’s Officer’s to discuss how the Trust will provide such a transcript to you.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 2023

    Open published response

  7. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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

    Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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 identify and disclose material call-handling information during investigation

    Wider context from the report

    “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case. It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 relevant witnesses and providing witness statements for coronial investigations

    Wider context from the report

    “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to coordinate complete and appropriately recorded disclosure for coronial investigations

    Wider context from the report

    “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”

    Source location

    JACK OLIVER PORTLAND · 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

    Route all future disclosure to the Coroner’s Court through Government Legal Department to avoid confusion.

    Verbatim wording from the response

    “Disclosure We regret that the provision of documents to this inquest was not achieved in the way that we would wish, and would like to apologise to you for the impact that this had on the inquest process. Much of this difficulty arose from the fact that, as Mr Portland died some months after his release from HMP Woodhill and when he was not in prison custody, the usual process by which prisons ensure that the paperwork required for disclosure to assist the Prison and Probation Ombudsman’s investigation and the Coroner’s Inquest is collated was not initiated. In consultation with GLD, we have agreed that in future all disclosure to the Coroner’s Court will be done through GLD to avoid confusion.”

    Source location

    2017-0049-Response-by-NOMS
    Page 3 · response
    Published 5 March 2017

    Open published response

  9. Inner North London

    AI-generated summary

    Terence Darren ADAMS · 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 Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

    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 and failures in disclosing root cause analyses to the coroner

    Wider context from the report

    “6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest, and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself. Its existence had not been disclosed to HM Coroner. ”

    Source location

    Terence Darren ADAMS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    Carl Robert FOOT · 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

    Carl Robert Foot was found hanging in his cell at HMP Pentonville after repeatedly ringing his cell bell. He was found at 3.18pm, resuscitated and died four days later in hospital. The jury found that prison officers responded inadequately to the cell bells, contributing to his death, and identified difficulties in determining how long a prisoner had been waiting and in reviewing the incident promptly.

    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 promptly examine cell bell logs and identify those who heard or answered bells

    Wider context from the report

    “3. In terms of learning lessons for the future, which may include learning by individual officers as well as on a systemic basis, there was no exploration immediately after Carl Foot’s death of the cell bell log and all those who heard/answered his bell that afternoon. By the time of inquest, memories had faded. ”

    Source location

    Carl Robert FOOT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026