Recurring concern

Failure of care and safety auditing to identify deficiencies

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First reported 28 May 2014•Latest report 16 Jun 2026

Definition

What this concern includes

Includes failures of audits or compliance-assurance processes specifically examining care and safety records, assessments, reviews, interventions, documentation or related operational practice where the audit fails to identify a material deficiency.

Not included

  • Excludes generic weaknesses in governance, staffing, training or documentation unless the report directly ties them to failure of a care and safety audit.
  • Excludes deficiencies in the underlying care or safety process when no audit or assurance failure is identified.
  • Excludes audits of non-care public-safety activities, such as roads, signage or controlled-drug processes, unless they are explicitly part of the same care and safety auditing concern.
Reports
69

Distinct published reports

Individual concerns
76

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
85

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 Care11
NHS England7
Greater Manchester Mental Health NHS Foundation Trust5
Care Quality Commission4
HM Prison and Probation Service4
Ministry of Justice3
NHS Greater Manchester Integrated Care Board3
Association of Ambulance Chief Executives2
Avery Healthcare Group2
Birmingham and Solihull Mental Health NHS Foundation Trust2
East London NHS Foundation Trust2
Frimley Health NHS Foundation Trust2
Manchester University NHS Foundation Trust2
National Institute for Health and Care Excellence2
Practice Plus Group2

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. North East Kent

    AI-generated summary

    HARRY RICHFORD · 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

    Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

    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

    Uncertain auditing and logging of neonatal resuscitation pro forma completion

    Wider context from the report

    “Concern 15 The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged, or what actions are being done to ensure its completion and preservation. ”

    Source location

    HARRY RICHFORD · Prevention of Future Deaths report
    Page 18 · concerns

    Open source report

    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 is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

    Verbatim wording from the response

    “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 October 2022

    Open published response

  2. Inner North London

    AI-generated summary

    Shanté Andrée Marie TURAY-THOMAS · 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

    Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.

    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 of 111 call audits to identify all significant call-handling failings

    Wider context from the report

    “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways. Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement. ”

    Source location

    Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
    Page 6 · 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

    Develop and apply an audit framework for NHS Pathways providers, including audit standards, frequencies, qualifications and training requirements.

    Verbatim wording from the response

    “NHS Digital has developed an extensive audit framework that applies to providers using NHS Pathways. This was described in NHS Digital’s: supplementary second witness statement dated 20th December 2019; submissions on conclusion dated 3 January 2020; and PFD submissions dated 17 January 2020.”

    Source location

    2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
    Page 2 · response
    Published 13 August 2020

    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

    Providers are responsible for operating the audit system and managing failed call audits within NHS Digital’s framework.

    Verbatim wording from the response

    “Clinical providers of services using NHS Pathways (‘providers’) must enter into a Licence Agreement with the Secretary of State for Health and Social Care, including requirements relating to implementation, operation, training and auditing. This licence and the supporting materials are managed by NHS Digital.”

    Source location

    2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
    Page 2 · response
    Published 13 August 2020

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    David Jonathon Jukes · 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

    David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

    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 staff compliance with record-keeping duties is detected

    Wider context from the report

    “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected. ”

    Source location

    David Jonathon Jukes · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    Care and treatment concerns are largely for provider organisations to resolve.

    Verbatim wording from the response

    “2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 26 July 2019

    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

    Local NHS agencies are expected to address the report’s local concerns.

    Verbatim wording from the response

    “Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.”

    Source location

    2019-0220-Response-by-NHS-England
    Page 1 · response
    Published 26 July 2019

    Open published response

  4. West London

    AI-generated summary

    Sophie Bennett · 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

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    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

    Inadequate duration of change-related audit

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    Natasha Learline CHIN · 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

    Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.

    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 audit of nurse prescribing and pre-prescription record checks

    Wider context from the report

    “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff. 2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend. 3. Nurses failed to make any datix referrals in respect of missed medications. 4. The following matters have to date not been formally audited by Sodexo Justice Services: i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded. ii.) Whether critical medication is administered on time. iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal. iv.) Whether medical records on System 1 are accurately recorded. v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive. 5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed. 6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter. 7. Whether there is adequate training: i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal. ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales. ”

    Source location

    Natasha Learline CHIN · Prevention of Future Deaths report
    Page 4 · 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

    Lack of audit of medical-record accuracy on System 1

    Wider context from the report

    “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff. 2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend. 3. Nurses failed to make any datix referrals in respect of missed medications. 4. The following matters have to date not been formally audited by Sodexo Justice Services: i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded. ii.) Whether critical medication is administered on time. iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal. iv.) Whether medical records on System 1 are accurately recorded. v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive. 5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed. 6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter. 7. Whether there is adequate training: i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal. ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales. ”

    Source location

    Natasha Learline CHIN · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  6. Wiltshire and Swindon

    AI-generated summary

    Terence Andrew Bennett · 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 Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working 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

    Lack of external audit of care plans and medical records

    Wider context from the report

    “4. There did not appear to be a system of peer review within the mental health teams nor a system of external audit as regards the adequacy of care plans and medical records. ”

    Source location

    Terence Andrew Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Venkata Naga Lakshyasi KAGGA · 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

    Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.

    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 POAU audit systems for detecting noncompliance

    Wider context from the report

    “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system. ”

    Source location

    Venkata Naga Lakshyasi KAGGA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Janet Silva Müller · 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

    Janet Silva Müller, a patient detained under Section 2 of the Mental Health Act 1983 at Millview Hospital, died on 13 March 2015 after being found in the boot of a burning car; the circumstances were recorded as unlawful killing following her absconding from hospital. The principal concerns were incomplete and contradictory records, handovers, risk assessments and care plans, inadequate staffing, and insufficient measures to prevent detained patients from absconding.

    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 of auditing of nursing records to identify documentation gaps

    Wider context from the report

    “1. Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory. Whilst we were told that regular auditing is carried out by the Trust of nursing records it is clear that this is not fit for purpose as it is did not identify the fact that there were gaps in Janet’s nursing records and other key documents. The lack of proper record keeping increased Janet’s risk. ”

    Source location

    Janet Silva Müller · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Buckinghamshire

    AI-generated summary

    ARTHUR ALBERT MORLEY · 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

    Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.

    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 audit of wing and night staff inspection duties

    Wider context from the report

    “(5) There has been no specific audit of wing and night staff duties to include wing room and sanitation area inspections during lock up. Mr Morley appears to have made use of a chair in the sanitation room, but no witnesses could be certain as to how the chair had got there and from where it had come. ”

    Source location

    ARTHUR ALBERT MORLEY · Prevention of Future Deaths report
    Page 1 · 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

    Lack of specific audit of wing ligature points

    Wider context from the report

    “(1) The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms, which remain accessible at night to prisoners but are out of view of wing staff. There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes. ”

    Source location

    ARTHUR ALBERT MORLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. South Yorkshire (Western)

    AI-generated summary

    Mr Simon Timothy Harper · 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 Simon Timothy Harper was admitted to hospital with jaundice and abdominal distention and later developed multiple organ failure. During his transfer to intensive care, his portable oxygen cylinder was not turned on; he suffered a cardiorespiratory arrest, was resuscitated, and died after treatment was withdrawn. Concerns included inadequate documented training and lack of a suitable transfer policy for using portable oxygen cylinders.

    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 audit of the appropriateness of on-the-job portable oxygen cylinder training

    Wider context from the report

    “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training. The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this. The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue. ”

    Source location

    Mr Simon Timothy Harper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026