Recurring concern

Unreliable preservation and disclosure of material for death investigations

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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. 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
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Data last updated 7 September 2026