Recurring concern

Unsafe management of operational protocol changes

First to latest report 7 Oct 2014 — 4 Oct 2023

Reports that mention this concern
10
Times this concern has been raised
14
Stated actions linked to this concern
8

What this concern includes

Includes deficiencies in the management of explicitly identified operational protocol changes, including communication, staff understanding or training, publication, supersession control and implementation of the changed protocol.

What is not included
  • Excludes generic staff training deficiencies not tied to an operational protocol change.
  • Excludes generic communication, documentation or policy-governance failures not specifically concerning an operational protocol change.
  • Excludes failures involving the substantive content of a protocol where the issue is not the management or implementation of a change.

Reports and published responses 10 reports

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

  1. Herefordshire

    AI-generated summary

    Ronald Leslie HARRIS · 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

    Ronald Leslie Harris’s family contacted the practice in April 2023 about worsening mental health difficulties and requested further help, but a routine appointment was offered with a stated 4–6 week wait and no follow-up call was made. He died by suicide on 5 June 2023. Concerns included incomplete triage documentation, failure to make the requested call, and the triage doctor’s lack of awareness of the waiting time and the telephone-call transcript; a review of mental-health triage protocols was noted, but no revised protocol had been advised by 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

    Unavailability of a revised protocol for triaging patients with mental health problems

    Wider context from the report

    “(4) The Deceased died on the 5th June 2023. The Inquest was told that a significant event meeting on the 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken. The Inquest was held on the 27th September 2023 no revised protocol was advised. ”

    Source location

    Ronald Leslie HARRIS · 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

    Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.

    Verbatim wording from the response

    “We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

    Source location

    Response from Hereford Medical Group
    Page 2 · response
    Published 18 October 2023

    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 existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.

    Verbatim wording from the response

    “We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

    Source location

    Response from Hereford Medical Group
    Page 2 · response
    Published 18 October 2023

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Kyle Nicholas James Hurst · 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

    Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic results.

    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 adopt accelerated N-acetylcysteine administration into a standard operating protocol

    Wider context from the report

    “1. Evidence given at the inquest by the ED Consultant indicated that it has been recognised that the accelerated administration of N-Acetylcysteine may be beneficial in the treatment of a ████████ but this has not yet been adopted into a Standard Operating Protocol despite this having been proposed in August 2021 ”

    Source location

    Kyle Nicholas James Hurst · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Cambridgeshire and Peterborough

    AI-generated summary

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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

    Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.

    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 managerial policy-change controls to prevent recurrence of superseded-policy confusion

    Wider context from the report

    “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced. ”

    Source location

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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

    Audit contacts to the Integrated Front Door and address uncertainty about statutory duties and relevant mental health policies.

    Verbatim wording from the response

    “the specific teams that hold most of these type of cases. There is one route through which new contacts in relation to young people with mental health difficulties can be made, and staff in the Integrated Front Door (who review all such requests for services) have been required to familiarise themselves with our statutory duties and the relevant policy documents. We operate a frequent audit dip sample process around all contacts, and any areas where there may still be uncertainty are picked up through that process and addressed.”

    Source location

    2021-0184-Response-from-Cambridgeshire-County-Council_Published
    Page 7 · response
    Published 2 June 2021

    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

    Clarify which AWOL policy has been superseded.

    Verbatim wording from the response

    “CPFT accepts the concerns with regard to the AWOL policy and has commenced the process of reviewing this. In order to ensure that the concerns about meaningfulness and useability are fully addressed this will involve engagement with staff groups, service users and carers. That work is expected to be completed by October 2021. In the meantime clarity has been given with regard to the superseded policy.”

    Source location

    2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 2 June 2021

    Open published response

  4. Sunderland

    AI-generated summary

    Darren James Powney · 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

    Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.

    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 emergency staff to be aware of the applicable protocol

    Wider context from the report

    “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through. I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid. Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention. For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest. ”

    Source location

    Darren James Powney · Prevention of Future Deaths report
    Page 3 · 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 a firm, clear training programme for the new protocol

    Wider context from the report

    “The safety of our emergency responders is very important, and sadly they appear to be the subject of violence or the threat of it. Darren’s death has highlighted the process our emergency responders now have to go through. I heard evidence about the reviews of procedures undertaken since Darren’s death, but I still have concerns. I was dismayed to hear about the confusion that arose, and that some NEAS staff were still not aware of the Protocol dated August 2016. It appeared that the dynamic risk assessment undertaken did not facilitate ambulance crews requesting further information or clarification, as the markers could unintentionally build a picture about an individual. In Darren’s case I was surprised there was not a bespoke policy for him given that he had called 21 times since May 2016. I heard evidence about the proposed escalation to senior managers should such confusion reoccur, but with an 8 minute response time that escalation must be rapid. Although a lot of work has been done, I am concerned there appears to me more to be done, implemented and trained upon sooner, rather than later. Nearly a year on and, although the new protocol may be on the cusp of being agreed, there is nothing firm enough in my view in place with a clear training programme. In any event I hope my Report will give the necessary impetus to conclusion and implemention. For Darren the confusion, which led to delay, made no difference, but for someone else it might. As this issue may have more than implications locally I have copied in others who may have an interest. ”

    Source location

    Darren James Powney · 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

    Disseminate Joint Operating Procedure and dynamic-risk-assessment guidance through staff briefings, memoranda, meetings, face-to-face sessions, induction and operational assurance activities.

    Verbatim wording from the response

    “We have undertaken a range of measures to ensure staff understand the JOP and how it applies to them in practice as follows:”

    Source location

    2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
    Page 3 · response
    Published 5 February 2018

    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

    Audit frontline staff knowledge and awareness of the Joint Operating Procedure.

    Verbatim wording from the response

    “• Our staff's knowledge and awareness of the JOP is to be audited;”

    Source location

    2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
    Page 6 · response
    Published 5 February 2018

    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

    Formal collective launch of the Joint Operating Procedure was considered ceremonial because stakeholders had already agreed and used it in daily routines.

    Verbatim wording from the response

    “The Trust can confirm that the JOP is currently being used by the stakeholders and will continue to evolve as part of the Trust's collaborative work with Police colleagues. Whilst the JOP has not yet been formally collectively launched, plans are being made for the various Executive teams to meet and jointly sign the current version. The dates suggested for this meeting commence on the 6th February 2018 with partners being asked to provide availability. The plans also include a joint media launch so the work can be publically shared to show the on-going collaboration between the emergency services. The Trust would however like to assure you that this is more of a ceremonial matter linked with promoting our collaboration. As stated above all three Police Forces and the Trust have agreed the JOP and use it in our daily routines.”

    Source location

    2017-0346-Response-by-North-East-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 5 February 2018

    Open published response

  5. 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

    Delays in reviewing, amending and publishing revised LOPs

    Wider context from the report

    “(4) The need to review and amend Local Operating Procedures LOP48 (Communications Room) and LOP49 (Access to Ablutions) has emerged through the investigation and a number of key measures have been introduced, however the need for staff to be able to access, understand and implement revised written protocols remains and there was no particular timescale indicated within which these changes might be made and new LOPs published. Mr Morley’s death enabled the identification of shortcomings in knowledge and implementation of existing LOP procedures. There is a concern that staff uncertainty about operational protocols will continue until new LOPs are in place and staff are appropriately trained. ”

    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

    Failure to ensure staff understanding and implementation of operational protocols

    Wider context from the report

    “(4) The need to review and amend Local Operating Procedures LOP48 (Communications Room) and LOP49 (Access to Ablutions) has emerged through the investigation and a number of key measures have been introduced, however the need for staff to be able to access, understand and implement revised written protocols remains and there was no particular timescale indicated within which these changes might be made and new LOPs published. Mr Morley’s death enabled the identification of shortcomings in knowledge and implementation of existing LOP procedures. There is a concern that staff uncertainty about operational protocols will continue until new LOPs are in place and staff are appropriately trained. ”

    Source location

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

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Dipa Rameshchandra Lad · 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

    Dipa Lad died after using an item of clothing to ligate on 4 March 2016; the medical cause of death was ligature pressure to the neck. The principal concerns related to differences between national guidance and the local ambulance protocol for stopping resuscitation, including the lack of guidance on when resuscitation was futile, staff awareness and training, and the clarity of the procedure. A further concern related to the technique used by one technician when giving chest compressions.

    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 verification that staff have read and understood protocol changes

    Wider context from the report

    “4. We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change. ”

    Source location

    Dipa Rameshchandra Lad · 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

    Lack of training on the protocol change

    Wider context from the report

    “4. We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change. ”

    Source location

    Dipa Rameshchandra Lad · 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 ensure staff awareness of changes to resuscitation policy

    Wider context from the report

    “3. It was clear that most of the staff attending this emergency were not aware of the change in local policy. On arrival of the team leader (who told us she was aware of the protocol), resuscitation efforts were stopped. I am concerned about the clear disparities in awareness of this important change to protocol. ”

    Source location

    Dipa Rameshchandra Lad · 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

    Introduce a clinical-information dissemination procedure using risk-based bulletins with mandatory receipt and understanding confirmation for critical updates, supported by weekly monitoring.

    Verbatim wording from the response

    “To ensure that key information around changes to clinical practice are disseminated to clinical staff in July 2016 EMAS introduced a revised version of the Procedure for the Dissemination of Clinical Information to Clinical Staff Members.”

    Source location

    2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    Open published response

  7. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · 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

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    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 formal training and detailed understanding of the current overdose policy

    Wider context from the report

    “3. Upon obtaining the contract for healthcare at HMP Durham, G4S have instituted have implemented a new policy, but evidence was given that staff had not been given any formal training on it, though the document (running to 12 pages) had been emailed. Evidence indicated that there was still a lack of appreciation of the detail of the policy now in force. ”

    Source location

    Kevin Anthony Forster · 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

    Introduce monthly multidisciplinary substance misuse training for healthcare, discipline and other prison staff.

    Verbatim wording from the response

    “2. We have introduced, under the leadership of Dr Bray, a monthly training event specific to all aspects of substance misuse issues which is held monthly on a Friday afternoon in the Prison Training Centre. The training event is open to all staff at the prison from all disciplines of the various organisations within the prison and wider region, both healthcare staff and discipline staff. Each session usually lasts for a couple of hours. The training is a mixture of white board training, discussion, group work, multi-disciplinary discussions, sharing information and experiences and clinical reviews. This training reinforces the seriousness of substance misuse and overdose issues and emphasises the inappropriateness and unacceptability of attitudes of complacency and acceptance towards the issues.”

    Source location

    2015-0453-Response
    Page 3 · response
    Published 28 October 2015

    Open published response

  8. South London

    AI-generated summary

    Anne Wilson · 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

    Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.

    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 training for staff handling welfare check requests in the new policy

    Wider context from the report

    “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain: (a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised (b) an example of how to manage a request for a welfare check concerning the mental health of an individual (c) how to manage additional information received once a welfare check request had been closed. (d) The importance of updating those involved in the change in actions being taken by the MPS ”

    Source location

    Anne Wilson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. 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 formalise changes to the policy for inducting new staff

    Wider context from the report

    “(I) The failure to supervise the operating surgeon on her first day at work for this complex twin delivery. It was stated in evidence that the policy of inducting new staff had changed but that this had not been enshrined in any formal document. Such a document should be produced and a copy submitted to myself. ”

    Source location

    Thor Harrison Dalhaug · 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

    Implement the comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.

    Verbatim wording from the response

    “As indicated in the evidence heard at inquest, the Trust has now taken various steps to significantly reduce the chance of such a situation occurring again. In particular, all junior doctors will now:-”

    Source location

    2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
    Page 2 · response
    Published 6 March 2015

    Open published response

  10. North Wales (East and Central)

    AI-generated summary

    Timothy Peter Cowen · 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

    Timothy Peter Cowen underwent surgery on 23 April 2013 and subsequently developed bilateral extensive pneumonia with features of aspiration. He died on 2 May 2013 after deterioration and readmission to hospital. Concerns included non-mandatory training on new procedures and insufficient cover for Acute Liaison Nurses during absence.

    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 mandate training on new procedures and protocols for all staff requiring awareness

    Wider context from the report

    “1. That although a Root Cause Analysis undertaken by the health board has resulted in new training bundles being produced, training is not mandatory for all staff who would require to be made aware of the new procedures and protocols. ”

    Source location

    Timothy Peter Cowen · 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