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. Central Lincolnshire

    AI-generated summary

    Thor Harrison Dalhaug · 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

    Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of 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 identify and rectify missing full notes after a death

    Wider context from the report

    “(IV) The failure to identify in the immediate aftermath of Thor's death that the operating surgeons had neglected to make a full note of the circumstances in which he died and to obligate them to provide the same; in particular ████████ was advised to amend the Caesarean pro forma, to include the fact that forceps were used in the interests of candour. He was then dissuaded from doing so by senior management as a result of their concerns as to how this would be perceived if the matter was investigated. This raises very serious concerns as to the degree of candour in disclosing the circumstances of this death. What steps have been taken to obviate a repetition of this behaviour in the future? ”

    Source location

    Thor Harrison Dalhaug · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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