Recurring concern

Unreliable root cause analysis processes

First to latest report 3 Dec 2013 — 14 May 2024

Reports that mention this concern
26
Times this concern has been raised
27
Stated actions linked to this concern
56

What this concern includes

Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.

What is not included
  • Excludes generic incident investigation or organisational-learning failures where root cause analysis is not the specifically identified process.
  • Excludes failures in implementing safety actions where no root cause analysis or root cause analysis action plan is involved.
  • Excludes generic clinician training deficiencies unrelated to undertaking root cause analysis.
  • Excludes deficiencies in the underlying clinical or operational process investigated when the root cause analysis process itself is not unsafe.

Reports and published responses 26 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Andrew Peter Wells · 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

    Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.

    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 robust and effective root cause analysis of serious incidents

    Wider context from the report

    “1. The Trust’s Internal Root Cause Analysis investigation reviewed the decision making of the clinicians including the role of the treating consultant psychiatrist, the unit’s Responsible Clinician. However, on one on the investigation team was a psychiatrist, or of a similar status to the Responsible Clinician. The RCA report agreed with the Responsible Clinician that the decision making around Mr Wells’ informal status and observation levels was appropriate. The draft RCA report went through a governance exercise, and a member happened to be a consultant psychiatrist, but this did not involve scrutiny of the evidence. I agreed with the evidence from an independent expert consultant psychiatrist that the decision making of the clinicians, including the Responsible Clinician, was not appropriate. Therefore, my on-going concern is that the Trust’s RCA process is not robust or effective enough to learn lessons from serious incidents. ”

    Source location

    Andrew Peter Wells · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Roger Albert NEAVES · 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

    Roger Albert Neaves fell in his bedroom on 16 October 2018, fractured his left femur, was taken to hospital, deteriorated and died on 18 October 2018. The Coroner was concerned to receive confirmation that recommendations from the Hospital Trust’s Root Cause Analysis had been fulfilled.

    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 confirmation of fulfilment of Root Cause Analysis recommendations

    Wider context from the report

    “The Coroner received evidence from ████████ the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves’s death. That Root Cause Analysis made various recommendations which required action by the Hospital Trust. The Coroner is concerned to receive confirmation that the recommendations have been fulfilled. ”

    Source location

    Roger Albert NEAVES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. South Wales Central

    AI-generated summary

    Calary Fern Davis · 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

    Calary Fern Davis was delivered by emergency Caesarean Section on 31st December 2017 after fetal bradycardia caused hypoxic ischaemic encephalopathy and very serious brain damage, and she later died from that condition. The report identified concerns about failures in the induction pathway, including a lack of planned obstetric review, delay in artificial rupture of membranes, insufficient staffing and leadership, poor communication and safety briefings, and a culture against performing artificial rupture of membranes at night.

    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

    Incomplete action plans annexed to root cause analyses

    Wider context from the report

    “(1) The action plan annexed to the root cause analysis remained incomplete. It is understood that this arises in part from the merger of the maternity services of the Royal Glamorgan and the Prince Charles Hospitals. ”

    Source location

    Calary Fern Davis · 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

    Update and monitor individual and overarching maternity services improvement action plans through governance boards.

    Verbatim wording from the response

    “Actions implemented: The action plan annexed to the root cause analysis remained incomplete. It is understood that this arises in part from the merger of the Maternity Services of the Royal Glamorgan and the Prince Charles Hospitals. A corrective Action Plan for Improvement was developed following Calary Davis’ death. This has been updated to reflect the concerns identified within the Regulation 28 Report. The individual action plan has a completion date of August 2019, however, work is ongoing for the overarching maternity services action plan. All plans will be monitored through the Improvement Board and the Quality Safety Board.”

    Source location

    2019-0043-Response-by-University-Health-Board
    Page 1 · response
    Published 24 May 2019

    Open published response

  4. Exeter and Greater Devon

    AI-generated summary

    Naomi Clare Sourbut · 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

    Naomi Clare Sourbut, who had a history of anxiety, depression, self-harm and bulimia, self-administered an overdose of medication, most probably Venlafaxine, and died after developing hypoxic brain injury. Concerns included whether recommendations from a root cause analysis had been considered and implemented, and whether protective factors were put in place after she reported suicidal intent and access to medication.

    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 ensure consideration and implementation of root cause analysis recommendations

    Wider context from the report

    “(1) A root cause analysis investigation was undertaken by the Devon Partnership Trust and that report was finalised on the 8th September 2017. The report contained a number of identified lessons learned and recommendations, ten in total (see attached annexe), applicable to different teams within Devon Partnership Trust. It was unclear at the Inquest as to whether or not these recommendations have been considered and acted upon by the teams to which they were directed particularly where clients have talked of suicidal ideation and identified the means with which to bring about their death. In my opinion action should be taken to prevent future deaths and I believe you and your organisation has to take such action to confirm the recommendations in the root cause analysis report File No: 2017/10523 NON ANON RCA JHNS 18.9.17 – having been considered and implemented. ”

    Source location

    Naomi Clare Sourbut · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Liverpool and the Wirral

    AI-generated summary

    Paul James Maddox · 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

    Paul James Maddox was admitted to hospital with vomiting and subsequently developed severe internal bleeding after a fall in haemoglobin was not acted upon. He underwent emergency surgery after deteriorating, but died from massive gastrointestinal bleeding with disseminated intravascular coagulopathy. The principal concern was the missed opportunity to detect, investigate and treat the bleeding, with strategies to prevent recurrence still described as work in progress at the inquest.

    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 implement strategies to prevent recurrence of the identified failure

    Wider context from the report

    “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress. The missed opportunity was not acting upon a reducing trend in a haemoglobin result. This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident. During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians” The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented ”

    Source location

    Paul James Maddox · 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

    Establish a weekly Serious Incident meeting to review new incidents, report progress, and flag overdue actions.

    Verbatim wording from the response

    “• A new Serious Incident meeting has been set up and meets on a weekly basis after the safety summit to review new incidents and the progress of reports. Any issues with out of date actions can be flagged at this meeting.”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 2 · response
    Published 24 September 2017

    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

    Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.

    Verbatim wording from the response

    “• Changes to the lab IT system have been made and an action notice has been issued to all staff informing them of the agreed changes to our standard operating procedure around Hb reporting”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 2 · response
    Published 24 September 2017

    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

    Reduce the haemoglobin delta-check threshold from 25% to 20%.

    Verbatim wording from the response

    “• The delta check value for Hb has changed from 25% to 20%. There is currently no delta check in the Royal College guidance.”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 2 · response
    Published 24 September 2017

    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

    Raise the haemoglobin telephone-alert threshold from below 70 g/L to below 75 g/L and audit its operation.

    Verbatim wording from the response

    “• The telephone criteria for Hb has changed from less than 70g/l to less than 75g/l and continues to be audited.”

    Source location

    2017-0220-Response-by-Wirral-University-Teaching-Hospital
    Page 3 · response
    Published 24 September 2017

    Open published response

  6. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · 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

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    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 timely progress in addressing previously recognised care failings

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Southampton and New Forest

    AI-generated summary

    Grant David Burns · 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

    Grant David Burns took an excess quantity of methadone, heroin and Alprazolam while alone at The Booth Centre between 20.05 on 22 July and 15.15 on 23 July 2016, and died from Morphine, Methadone and Alprazolam Toxicity. Concerns included a lack of co-operative working and communication between mental health, substance misuse and partner agencies, and an incomplete Root Cause Analysis report due to missing input from a key worker.

    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 key worker input for root cause analysis

    Wider context from the report

    “The Southern Health report highlighted that their report was incomplete because there was no input from the key worker at New Road despite best efforts ”

    Source location

    Grant David Burns · 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

    Review Serious Incident Requiring Investigation policies to require investigators to engage all known stakeholders and services involved in a person’s care.

    Verbatim wording from the response

    “In relation to issue 2, namely the report being incomplete because there was no input from the key worker at New Road, a number of actions have been put in place. In this particular instance, the incomplete reports were due to lack of input from both Substance Misuse Services and Adult Mental Health in relation to Serious Incident Requiring Investigation reports. In order to avoid this from happening again an action has been put in place to review the current Serious Incident Requiring Investigation policies for both Southern Health Foundation Trust and Solent NHS Trust to ensure the explicit requirement of Serious Incident requiring investigation investigators to engage with all key stakeholders/services who were/are involved in a person’s care, and offer them input into the investigation process.”

    Source location

    2017-0048-Response-by-Solent-NHS-Trust
    Page 2 · response
    Published 5 March 2017

    Open published response

  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

    Failure to complete timely and accurate Root Cause Analysis reports

    Wider context from the report

    “(5) The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event. The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports. The recommendations of the second RCA indicate reviews to be conducted by February/March 2017 but do not appear to address more urgent practical action or possible staff training needs. ”

    Source location

    JACK OLIVER PORTLAND · 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

    Provide dedicated full-time RCA investigator capacity in the adult mental health directorate.

    Verbatim wording from the response

    “- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016. - The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016. - Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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

    Monitor RCA investigation allocation, progress and timeliness weekly, with quarterly reporting to the Board of Directors.

    Verbatim wording from the response

    “- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016. - The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016. - Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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

    Survey RCA investigators to assess whether training changes meet their needs.

    Verbatim wording from the response

    “- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs. - The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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

    Commission an external review of the quality of serious-incident investigations to identify improvements.

    Verbatim wording from the response

    “- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs. - The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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 RCA investigator training and develop an additional module on involving and working with families.

    Verbatim wording from the response

    “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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

    Deliver the revised RCA training, including the additional family-involvement module.

    Verbatim wording from the response

    “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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

    Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.

    Verbatim wording from the response

    “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017). - The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017). - New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017). - The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 5 · response
    Published 5 March 2017

    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 second RCA did not need to revisit immediate actions because the initial review had already identified them and the actions required.

    Verbatim wording from the response

    “An initial review is completed for every serious incident, as was the case following Mr Portland’s death. Each initial review report should be completed within 5 days of the incident/death, reviewed by the senior clinical team and also by a weekly Trust wide executive meeting. The purpose of the initial review report is to set out the initial facts known, to identify any immediate action or learning required and to help develop the scope for the RCA investigation. The initial review report into Mr Portland’s death identified three immediate actions all around the timeliness of initiating the AWOL procedure. The initial review report was shared with the CQC.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 5 March 2017

    Open published response

  9. West Sussex

    AI-generated summary

    Matthew Christopher Roberts · 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

    Matthew Christopher Roberts, a music student with a history of psychosis and a previous intentional insulin overdose, took a large overdose of insulin and prescribed psychotropic medication after returning to Sussex. He was admitted to intensive care in a coma with significant hypoxic brain damage and later died from a major haemorrhage at the tracheostomy site caused by acute arteritis of the innominate artery. Concerns included failures to log and scrutinise referral faxes, consider written clinical and risk information before assessing urgency, confirm the date of first contact, and formally review the death and seek relevant learning.

    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 seek and obtain final RCA reports from external organisations

    Wider context from the report

    “(4) That SPFT did not appear to have undertaken any formal review of the death of someone known to the organisation and, although SPFT were aware a RCA was being conducted by Avon and Wiltshire NHS Trust, SPFT had not received nor sought that final RCA report from Wiltshire. An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest, almost a year after events. ”

    Source location

    Matthew Christopher Roberts · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  10. 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

    Failure to share root cause analyses with relevant internal safety and healthcare leaders

    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

    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

    Automatically provide redacted root-cause analyses of relevant deaths to the prison Governor going forward.

    Verbatim wording from the response

    “RCAs are shared with NHS England as Commissioner (but staff names are redacted). We recognise that RCAs should be share in an open and transparent manner and the prison Governor will automatically receive (redacted) copies going forward. The findings of all RCA’s should be shared, reviewed and discussed during individual site Quality Assurance Meetings. This is the forum where Action plans should be agreed on and progressed forward. The importance of this will be presented by the in-house legal team at our next divisional Quality Assurance meeting.”

    Source location

    Response from Care UK
    Page 5 · response
    Published 26 July 2016

    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