Recurring concern

Inadequate safety incident investigations

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First reported 13 Dec 2008•Latest report 25 Jun 2026

Definition

What this concern includes

Includes initiation, evidence gathering, witness testing, factual accuracy, analysis, timeliness, investigator competence and reporting within investigations of deaths, serious incidents and patient, resident or operational safety events.

Not included

Police, conduct, regulatory or other investigations not directed at organisational safety learning
Failure to implement an unrelated safety action not arising from an incident investigation
Generic governance failures not directly affecting a safety incident investigation or its learning process
Excludes downstream dissemination, learning and corrective-action controls once the investigation findings have been established.

Reports: 244
Individual concerns: 316
Date range: 2008–2026
Stated actions: 447

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care31

Care Quality Commission21

NHS England20

Betsi Cadwaladr University LHB11

Barking, Havering and Redbridge University Hospitals NHS Trust10

Barts Health NHS Trust8

Greater Manchester Mental Health NHS Foundation Trust8

Pennine Care NHS Foundation Trust7

Essex Partnership University NHS Foundation Trust6

Nottinghamshire Healthcare NHS Foundation Trust5

Tameside and Glossop Integrated Care NHS Foundation Trust5

Tees, Esk and Wear Valleys NHS Foundation Trust5

Health and Safety Executive4

Medicines and Healthcare products Regulatory Agency4

NHS Greater Manchester Integrated Care Board4

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.

8 Sep2023
North West Wales
Concerns raised1
1. Investigation reports containing conflicting evidence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Revise and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.
  Stated by Betsi Cadwaladr University LHBStated in progress
AI-generated summary

Lynsey Sarah Smalley · 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

Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.

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
Investigation reports containing conflicting evidence
Wider context from the report
“a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future. ”
Source location
Lynsey Sarah Smalley · 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
Revise and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.

Verbatim wording from the response
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work. We are working in co-designing the process with staff and patient representatives, such as the independent Llais organisation, to implement a completely new and improved approach where the focus is on learning and improvement. During November 2023 we are meeting with the IHCs and Divisions for their collaboration and engagement in developing the process.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 14 September 2023
Open published response
4 Sep2023
Cheshire
Concerns raised1
1. Failure to investigate an operating-table death
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Emma Louise MORRISSEY · 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

Emma Louise Morrissey travelled to Turkey for gastric sleeve surgery and died on 08 July 2022 after an instrument perforated her abdomen during the operation, causing a massive uncontrolled bleed. Concerns included inadequate pre-operative assessment by the health tourism company, unclear health screening questions, lack of investigation into the death, inadequate embalming for repatriation, discrepancies in the surgical records and the reported cause of death, and the absence of platelets despite continued bleeding.

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 investigate an operating-table death
Wider context from the report
“3. There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation. ”
Source location
Emma Louise MORRISSEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
31 Aug2023
East London
Concerns raised1
1. Failure to undertake an adequately scoped serious investigation of community care incidents
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Review the case at the Pressure Ulcer Assurance Group to identify further care gaps and learning.
  Stated by North East London NHS Foundation TrustStated planned
2. Action
  Ensure incident reports capture concerns across integrated services.
  Stated by North East London NHS Foundation TrustStated planned
3. Action
  Implement PSIRF governance processes, including PSIG review of whether incidents require investigation and the appropriate investigation form.
  Stated by North East London NHS Foundation TrustStated completed
1. Action
  Investigate all pressure ulcers associated with sepsis through full Patient Safety Incident Investigations.
  Stated by North East London NHS Foundation TrustStated completed
2. Action
  Provide Directorate oversight and expert review of category 2–4 pressure-ulcer incidents and stronger or deep-tissue injuries.
  Stated by North East London NHS Foundation TrustStated completed
3. Action
  Establish multidisciplinary pressure-ulcer review panels and thematic learning through PSIG and the Pressure Ulcer Assurance Group.
  Stated by North East London NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  CQC criminal enforcement is unavailable because the incident does not meet the relevant enforcement threshold.
  Stated by Helen Whately MPUnable to act
AI-generated summary

Donna Levy · 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

Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.

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 undertake an adequately scoped serious investigation of community care incidents
Wider context from the report
“6. The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time. ”
Source location
Donna Levy · 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
Review the case at the Pressure Ulcer Assurance Group to identify further care gaps and learning.

Verbatim wording from the response
“• Undertake a review of this case at the Pressure Ulcer Assurance Group to identify any further gaps in care and learning.”

Source location
Response from North East London Foundation Trust
Page 2 · response
Published 8 September 2023
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
Ensure incident reports capture concerns across integrated services.

Verbatim wording from the response
“• Ensure incident reports include concerns across integrated services.”

Source location
Response from North East London Foundation Trust
Page 2 · response
Published 8 September 2023
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
Implement PSIRF governance processes, including PSIG review of whether incidents require investigation and the appropriate investigation form.

Verbatim wording from the response
“With the introduction of the new Patient Safety Incident Response Framework, this has now changed. This framework includes new processes such as the Patient Safety Incident Report Group Forum (PSIG) that provides for greater and more detailed review of whether an investigation is needed and what form that will take. The PSIG is a NELFT wide meeting headed by the Executive Chief Nursing Officer and attended by, but not limited to, representatives at various levels from the different Directorates, Directors, Assistant Directors, Operational Leads, the Legal Team and the Patient Safety Team.”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 8 September 2023
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
Investigate all pressure ulcers associated with sepsis through full Patient Safety Incident Investigations.

Verbatim wording from the response
“As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 8 September 2023
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
Provide Directorate oversight and expert review of category 2–4 pressure-ulcer incidents and stronger or deep-tissue injuries.

Verbatim wording from the response
“As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 8 September 2023
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
Establish multidisciplinary pressure-ulcer review panels and thematic learning through PSIG and the Pressure Ulcer Assurance Group.

Verbatim wording from the response
“As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 8 September 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
CQC criminal enforcement is unavailable because the incident does not meet the relevant enforcement threshold.

Verbatim wording from the response
“In addition, CQC reviewed the incident in line with their specific incident guidance and assessed that it does not meet the threshold for CQC to consider using its criminal”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 8 September 2023
Open published response
15 Aug2023
County Durham and Darlington
Concerns raised1
1. Failure to complete serious incident investigations within required timescales
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Maintain direct oversight of serious incident review performance and brief the Quality Assurance Committee and Board.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
2. Action
  Contract additional expert capacity to address delayed serious incident reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
3. Action
  Increase internal capacity by engaging leaders to complete incident reviews and prevent further delays.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
1. Action
  Adopt daily patient-safety-huddle processes to identify the required type of incident review earlier.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
2. Action
  Operate weekly review-progress meetings and monitor performance against the improvement trajectory.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
3. Action
  Modify documentation, review report templates and use standard operating procedures to support efficient review workflows.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
4. Action
  Expand subject-matter-expert categories to lead specific review types.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
5. Action
  Contract an external professional incident-review provider.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Exact completion dates for some serious incident reports cannot be predicted because final reports may not be available for review on time.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustUnable to act
AI-generated summary

Ian Darwin · 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

Ian Darwin died from multiple injuries after being found below ████████, Durham, on 6 March 2023. The report raises concern that Tees Esk and Wear Valleys NHS Foundation Trust routinely delays serious incident investigations, potentially allowing lethal hazards to persist and compromising investigations intended to prevent avoidable deaths. The inquest had not been heard and the investigation had not concluded at the time of the report.

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 serious incident investigations within required timescales
Wider context from the report
“Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”) routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths. The above-mentioned inquest has not been heard; there has been no finding that the present death was attributable to acts or omissions in care. Although arising in the present investigation, the matter of concern is general and has arisen in the context of other investigations. Despite past assurances that the material circumstances have been addressed, the facts of the present case demonstrate that they continue to exist. I am aware that on 19th July 2023, Assistant Coroner Janine Richards notified you of the same concern arising from matters revealed by another investigation. TEWV identified Ian Darwin’s death as a “serious incident” (“SI”) for the purposes of The Serious Incident Framework¹ (the Framework”). The SI investigation (“SI”) process-defined in the Framework- was the means employed by TEWV to investigate this SI. The Framework defines SIs as “events where the potential for learning is so great, or the consequences to patients… so significant that they warrant particular attention to ensure these incidents… are investigated thoroughly… and trigger actions that will prevent them from happening again”. SIs “include acts or omissions in care that result in… avoidable death…”. Further, the “occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm”. SI investigations are the means “to ensure that weaknesses in a system are identified, to understand what went wrong … and what can be done to prevent similar incidents happening again”. Discussing one of the seven key principles of the SI investigation- that they be Timely and Responsive- the Framework requires that SIs “must be reported without delay and no longer than 2 working days after the incident is identified”. One of “two key operational changes” introduced in the 2015 update was a single timeframe of 60 working days (from date of initial report) for completion of investigation reports. At an “early meeting” the investigator must “set out a realistic and achievable timescales and outcomes”. The present case: • Death occurred on 06.03.23; • I am informed that an investigator was initially appointed in around mid-June 2023; • By late June, TEWV were “unable to say” when the investigation would be complete; • The investigation is now expected to be complete in the week commencing 21.08.23 and its report to be finalised 18.09.23 The general situation: • TEWV SI death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification; • In some other cases delay is significantly longer than in the present; • Such delays affect cases of all levels of seriousness. ”
Source location
Ian Darwin · 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
Maintain direct oversight of serious incident review performance and brief the Quality Assurance Committee and Board.

Verbatim wording from the response
“I am responding in the same format and with similar information to that in the response letter sent last month, I hope this consistency will be helpful in enabling you and your team to see the clear evidence of the progress we are making towards providing timely serious incident reviews. I have continued to have direct oversight of how we are performing as I am concerned that we improve our position as soon as possible. Our CEO and our Board share this concern and therefore I am keeping our Quality Assurance Committee and our Board fully briefed.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 6 September 2023
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
Contract additional expert capacity to address delayed serious incident reviews.

Verbatim wording from the response
“1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed, this is a group of incidents that happened before February 2023. Some of these reviews are now being concluded and are going through the internal quality assurance checks before we share them with the families, submit to the ICS and to your office. The attached document gives the detail of this.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 6 September 2023
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
Increase internal capacity by engaging leaders to complete incident reviews and prevent further delays.

Verbatim wording from the response
“2) We have increased our internal capacity to review incidents by engaging our leaders in completing incident reviews in order that we can review incoming incidents and avoid further delays developing. We intend to continue to use some of this capacity and expertise in the future which is part of our plan to avoid delays in the future.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 6 September 2023
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
Adopt daily patient-safety-huddle processes to identify the required type of incident review earlier.

Verbatim wording from the response
“5) We have adopted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be PSIRF, guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 2023
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
Operate weekly review-progress meetings and monitor performance against the improvement trajectory.

Verbatim wording from the response
“7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 2023
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
Modify documentation, review report templates and use standard operating procedures to support efficient review workflows.

Verbatim wording from the response
“9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 2023
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
Expand subject-matter-expert categories to lead specific review types.

Verbatim wording from the response
“11) We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 2023
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
Contract an external professional incident-review provider.

Verbatim wording from the response
“11) We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 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
Exact completion dates for some serious incident reports cannot be predicted because final reports may not be available for review on time.

Verbatim wording from the response
“I have taken the opportunity to share a list of the serious incident reviews that we believe will be required by you and I have indicated the dates that we expect the internal quality assurance process to be taking place. You can reasonably expect to receive most finalised serious incident reports within 2 weeks of the internal review however some will take longer than two weeks depending on, and this is difficult to predict, when the final report is available for review.”

Source location
Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 6 September 2023
Open published response
14 Aug2023
Leicester City and South Leicestershire
Concerns raised1
1. Failure of Serious Incident investigations to provide robust critical analysis and identify learning for patient safety
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review the original Serious Incident report with input from the previously unavailable Locum Consultant.
  Stated by Leicestershire Partnership NHS TrustStated in progress
2. Action
  Obtain accreditation for the Trust’s Serious Incident investigation and review processes through the Royal College of Psychiatrists’ accreditation network.
  Stated by Leicestershire Partnership NHS TrustStated completed
Respondent positions 1
1. Position
  Current serious incident reporting processes meet a high standard, as demonstrated by national accreditation and subsequent improvement since the case investigation.
  Stated by Leicestershire Partnership NHS TrustDisputes the concern
AI-generated summary

Marie ZARINS · 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

Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.

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 Serious Incident investigations to provide robust critical analysis and identify learning for patient safety
Wider context from the report
“3) I remain gravely concerned about the inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident Investigation failed to identify the errors in the care provided to Miss Zarins making the use of the process somewhat otiose in this case. The failure to properly investigate led to the wholly untenable situation where errors in care were uncovered for the first time at inquest, which took place some 20 months after the date of death (due to witness availability). I am concerned that the lack of robust critical analysis and investigation of the care provided to Miss Zarins before her death has caused a delay to, and led to missed opportunities (for some staff) to learn lessons that are vital to patient safety. My concerns relating to the inadequacy of the Trust Serious Incident Investigations and the risks related to that go far beyond just the care provided by the CRISIS Team. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust. ”
Source location
Marie ZARINS · 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
Review the original Serious Incident report with input from the previously unavailable Locum Consultant.

Verbatim wording from the response
“As agreed during the inquest, contact details were shared with the Trust and the Locum Consultant is now engaging in our review of the original SI report.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 6 September 2023
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
Obtain accreditation for the Trust’s Serious Incident investigation and review processes through the Royal College of Psychiatrists’ accreditation network.

Verbatim wording from the response
“Earlier this year, the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) awarded accreditation to the Trust for our Serious Incident (SI) processes. This is a national quality improvement and accreditation network for Mental Health Trusts. This accreditation concentrates on the quality of investigations and reviews and ensures processes are in place to work meaningfully with patients, their families and staff equally to identify learning. We were awarded this accreditation in recognition of the high standard of SI reporting undertaken by the Trust in 2023. We believe that this demonstrates the pace and extent of improvement undertaken since the time of the SI report in relation to Miss Zarin’s death. We continue to build on this as we transition towards the Patient Safety Incident Response Framework.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 6 September 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
Current serious incident reporting processes meet a high standard, as demonstrated by national accreditation and subsequent improvement since the case investigation.

Verbatim wording from the response
“Earlier this year, the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) awarded accreditation to the Trust for our Serious Incident (SI) processes. This is a national quality improvement and accreditation network for Mental Health Trusts. This accreditation concentrates on the quality of investigations and reviews and ensures processes are in place to work meaningfully with patients, their families and staff equally to identify learning. We were awarded this accreditation in recognition of the high standard of SI reporting undertaken by the Trust in 2023. We believe that this demonstrates the pace and extent of improvement undertaken since the time of the SI report in relation to Miss Zarin’s death. We continue to build on this as we transition towards the Patient Safety Incident Response Framework.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 6 September 2023
Open published response
31 Jul2023
Norfolk
Concerns raised1
1. Failure to review relevant care notes during incident investigations
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eileen Marguerite WALSH · 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

Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

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 review relevant care notes during incident investigations
Wider context from the report
“7. The Director of Training and Operations referred to the Incident Investigation carried out internally and found that PIR sensors were not in use in Mrs Walsh’s room at the time of her fall. PIR sensors were referred to in witness evidence and also in Mrs Walsh’s Daily Care Notes. It was found at the inquest a PIR sensor was in Mrs Walsh's room at the time of her fall and the PIR sensor did not sound an alarm as required in the Care Plan, at the time of Mrs Walsh’s fall. It is a concern this investigation did not read Mrs Walsh’s Care Notes before reaching this conclusion when concerns that the PIR sensor did not sound could have been addressed. ”
Source location
Eileen Marguerite WALSH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jul2023
County Durham and Darlington
Concerns raised2
1. Failure to promptly obtain, secure and preserve relevant serious-incident evidence
2. Extensive and continuing delays in investigating serious incidents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 23
1. Action
  Contract and allocate additional expert reviewers to address delayed incident reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
2. Action
  Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
3. Action
  Use an external specialist company to review historical incident data and identify risks from delayed reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
1. Action
  Adapt processes to identify the required incident review type earlier through daily patient safety huddles.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
2. Action
  Hold weekly review-progress meetings, provide reviewer support and monitor performance against the review trajectory.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
3. Action
  Modify documentation, review report templates and use standard operating procedures to improve efficient review workflow.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
4. Action
  Increase Serious Incident Review Panel capacity to prevent internal quality assurance delaying review release.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
5. Action
  Continue expanding subject matter expert categories to lead specific types of incident reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
6. Action
  Establish Associate Director of Patient Safety and Deputy Chief Nurse roles to oversee review quality and support reviewer supervision.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
7. Action
  Contract and deploy additional expert capacity to address delayed incident reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
8. Action
  Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
9. Action
  Report weekly to Executive Directors on Duty of Candour compliance and review-related delays.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
10. Action
  Use an external incident-management specialist to review historical incident data and identify risks from delayed reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
11. Action
  Identify required review types earlier through daily patient-safety huddles using national PSIRF guidance.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
12. Action
  Hold weekly review-progress meetings and monitor performance against the established trajectory with executive reporting.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
13. Action
  Modify documentation, review report templates and use standard operating procedures to improve review efficiency and workflow.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
14. Action
  Increase Serious Incident Review Panel capacity to support quality assurance without delaying release of completed reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
15. Action
  Continue expanding subject-matter-expert categories to lead specific types of incident reviews.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
16. Action
  Establish senior patient-safety leadership roles to oversee review standards and provide reviewers with support and supervision.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
17. Action
  Complete inspections of six inpatient and community mental health services and the trust’s leadership and governance.
  Stated by Care Quality CommissionStated completed
18. Action
  Serve a requirement notice requiring the trust to resolve serious incident, mortality, incident review and complaints backlogs and prevent recurrence.
  Stated by Care Quality CommissionStated completed
19. Action
  Continue monitoring the trust’s progress in removing the serious incident backlog through the monthly quality board.
  Stated by Care Quality CommissionStated in progress
20. Action
  Monitor the trust’s compliance with the requirement concerning serious incident, mortality, incident review and complaints backlogs and take regulatory action if improvement is inadequate.
  Stated by Care Quality CommissionStated in progress
Respondent positions 2
1. Position
  Oversight of investigation quality is limited to inspecting and acting on delays or flaws in a provider’s investigation system.
  Stated by Care Quality CommissionOutside remit
1. Position
  The trust’s commissioners are better placed to improve the quality of the trust’s serious incident investigation processes.
  Stated by Care Quality CommissionRedirects responsibility
AI-generated summary

Kenneth Rippon · 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

Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.

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 promptly obtain, secure and preserve relevant serious-incident evidence
Wider context from the report
“(1) The serious objective investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with. (2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again. (3) The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services. (4) As a result of the delay in the serious incident Investigation and formulation of an action plan, many of the identified actions required to remedy these difficulties were still being actioned /completed relatively recently. (5) Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already begun to fade. This was concerning given the identified problem of clinical record keeping at the time of these events. (6) I am concerned that the extensive and continuing delays in investigating serious incidents may lead to further deaths, as lessons cannot be learnt and improvements made in a timely manner. I am also concerned that the quality of such investigations is compromised by the failure to complete memory capture forms and the passage of time before important evidence is secured. ”
Source location
Kenneth Rippon · 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
Extensive and continuing delays in investigating serious incidents
Wider context from the report
“(1) The serious objective investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with. (2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again. (3) The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services. (4) As a result of the delay in the serious incident Investigation and formulation of an action plan, many of the identified actions required to remedy these difficulties were still being actioned /completed relatively recently. (5) Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already begun to fade. This was concerning given the identified problem of clinical record keeping at the time of these events. (6) I am concerned that the extensive and continuing delays in investigating serious incidents may lead to further deaths, as lessons cannot be learnt and improvements made in a timely manner. I am also concerned that the quality of such investigations is compromised by the failure to complete memory capture forms and the passage of time before important evidence is secured. ”
Source location
Kenneth Rippon · 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
Contract and allocate additional expert reviewers to address delayed incident reviews.

Verbatim wording from the response
“1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed. Since, my previous update we have contracted / employed further reviewers and to date we have allocated 41 of these reviews which is an increase of 16 since my previous letter to you.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 28 July 2023
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
Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.

Verbatim wording from the response
“2) We have continued to increase our internal capacity to review incidents, our clinical and leaders are engaged across services in completing incident reviews in order that we can review incoming incidents and avoid further delays developing.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 28 July 2023
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
Use an external specialist company to review historical incident data and identify risks from delayed reviews.

Verbatim wording from the response
“4) An external company specialising in incident management has reviewed our historical incident data so that we can address the potential risks of missing issues and learning due to a delay with some reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Adapt processes to identify the required incident review type earlier through daily patient safety huddles.

Verbatim wording from the response
“5) We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be Patient Safety Incident Response Framework (PSIRF), guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Hold weekly review-progress meetings, provide reviewer support and monitor performance against the review trajectory.

Verbatim wording from the response
“7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Modify documentation, review report templates and use standard operating procedures to improve efficient review workflow.

Verbatim wording from the response
“9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Increase Serious Incident Review Panel capacity to prevent internal quality assurance delaying review release.

Verbatim wording from the response
“10) We have increased our internal Serious Incident Review Panel capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Continue expanding subject matter expert categories to lead specific types of incident reviews.

Verbatim wording from the response
“12) We will continue to expand our range of subject matter expert categories to lead specific types of reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Establish Associate Director of Patient Safety and Deputy Chief Nurse roles to oversee review quality and support reviewer supervision.

Verbatim wording from the response
“13) The Associate Director of Patient Safety commenced in post as planned from 19 July 23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 July 2023. Together they are ensuring that reviews are of the right standard and that reviewers have the right support and supervision to complete high quality reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Contract and deploy additional expert capacity to address delayed incident reviews.

Verbatim wording from the response
“1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed. Since, my previous update we have contracted / employed further reviewers and to date we have allocated 41 of these reviews which is an increase of 16 since my previous letter to you.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 28 July 2023
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
Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.

Verbatim wording from the response
“2) We have continued to increase our internal capacity to review incidents, our clinical and leaders are engaged across services in completing incident reviews in order that we can review incoming incidents and avoid further delays developing.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 28 July 2023
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
Report weekly to Executive Directors on Duty of Candour compliance and review-related delays.

Verbatim wording from the response
“have a clear term of reference for each review. We report weekly to the Executive Directors on our compliance with Duty of Candour to ensure there are no delays.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Use an external incident-management specialist to review historical incident data and identify risks from delayed reviews.

Verbatim wording from the response
“4) An external company specialising in incident management has reviewed our historical incident data so that we can address the potential risks of missing issues and learning due to a delay with some reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Identify required review types earlier through daily patient-safety huddles using national PSIRF guidance.

Verbatim wording from the response
“5) We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be Patient Safety Incident Response Framework (PSIRF), guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Hold weekly review-progress meetings and monitor performance against the established trajectory with executive reporting.

Verbatim wording from the response
“7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Modify documentation, review report templates and use standard operating procedures to improve review efficiency and workflow.

Verbatim wording from the response
“9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Increase Serious Incident Review Panel capacity to support quality assurance without delaying release of completed reviews.

Verbatim wording from the response
“10) We have increased our internal Serious Incident Review Panel capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Continue expanding subject-matter-expert categories to lead specific types of incident reviews.

Verbatim wording from the response
“12) We will continue to expand our range of subject matter expert categories to lead specific types of reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Establish senior patient-safety leadership roles to oversee review standards and provide reviewers with support and supervision.

Verbatim wording from the response
“13) The Associate Director of Patient Safety commenced in post as planned from 19 July 23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 July 2023. Together they are ensuring that reviews are of the right standard and that reviewers have the right support and supervision to complete high quality reviews.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 2 · response
Published 28 July 2023
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
Complete inspections of six inpatient and community mental health services and the trust’s leadership and governance.

Verbatim wording from the response
“As well as powers to prosecute in some cases, CQC regulates NHS providers and can require providers to make improvements. In April and May 2023 CQC completed inspections of six of the trust’s inpatient and community mental health services and an inspection of the trust’s leadership and governance which will be published on 25th October 2023.”

Source location
Response from Care Qaulity Commission
Page 2 · response
Published 28 July 2023
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
Serve a requirement notice requiring the trust to resolve serious incident, mortality, incident review and complaints backlogs and prevent recurrence.

Verbatim wording from the response
“To ensure the trust’s progress in this matter, CQC have served the trust with a requirement notice, as an outcome of our inspection processes under Regulation 17 (1) (2) (a) (b) Good Governance. This states that:”

Source location
Response from Care Qaulity Commission
Page 3 · response
Published 28 July 2023
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
Continue monitoring the trust’s progress in removing the serious incident backlog through the monthly quality board.

Verbatim wording from the response
“Due to the concerns relating to the backlog of serious incidents, CQC and other stakeholders have continued to monitor the trust’s progress with reducing this backlog and preventing reoccurrence of this issue.”

Source location
Response from Care Qaulity Commission
Page 6 · response
Published 28 July 2023
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 the trust’s compliance with the requirement concerning serious incident, mortality, incident review and complaints backlogs and take regulatory action if improvement is inadequate.

Verbatim wording from the response
“To ensure the trust’s progress in this matter, CQC have served the trust with a requirement notice, as an outcome of our inspection processes under Regulation 17 (1) (2) (a) (b) Good Governance. This states that:”

Source location
Response from Care Qaulity Commission
Page 3 · response
Published 28 July 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
Oversight of investigation quality is limited to inspecting and acting on delays or flaws in a provider’s investigation system.

Verbatim wording from the response
“CQC share the Coroner’s concerns. These were highlighted to the trust during our inspection in relation to the delays in completion of reports. However, CQC have a limited role in the oversight of the quality of investigations beyond our ability to inspect and take action when there are delays and flaws in a provider’s system. The NHS Serious Incident Framework (2015) sets out that “Providers are responsible for the safety of their patients, visitors and others using their services, and must ensure robust systems are in place for recognising, reporting, investigating and responding to Serious Incidents and for arranging and resourcing investigations. Commissioners are accountable for quality assuring the robustness of their providers’ Serious Incident investigations and the development and implementation of effective actions, by the provider, to prevent recurrence of similar incidents.””

Source location
Response from Care Qaulity Commission
Page 3 · response
Published 28 July 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 trust’s commissioners are better placed to improve the quality of the trust’s serious incident investigation processes.

Verbatim wording from the response
“CQC share the Coroner’s concerns. These were highlighted to the trust during our inspection in relation to the delays in completion of reports. However, CQC have a limited role in the oversight of the quality of investigations beyond our ability to inspect and take action when there are delays and flaws in a provider’s system. The NHS Serious Incident Framework (2015) sets out that “Providers are responsible for the safety of their patients, visitors and others using their services, and must ensure robust systems are in place for recognising, reporting, investigating and responding to Serious Incidents and for arranging and resourcing investigations. Commissioners are accountable for quality assuring the robustness of their providers’ Serious Incident investigations and the development and implementation of effective actions, by the provider, to prevent recurrence of similar incidents.””

Source location
Response from Care Qaulity Commission
Page 3 · response
Published 28 July 2023
Open published response
12 Jun2023
Inner North London
Concerns raised1
1. Omissions from serious incident investigations
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the Trust’s responses and related reports to determine whether further action is needed.
  Stated by NHS EnglandStated planned
Respondent positions 1
1. Position
  Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
  Stated by NHS EnglandOutside remit
AI-generated summary

Heather FINDLAY · 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

Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational 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
Omissions from serious incident investigations
Wider context from the report
“6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident. At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself. It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future. However, • the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and • any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection. So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff. I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020. This position seems lacking the necessary reflection. I draw your attention to earlier prevention of future deaths reports (PFDs) as follows: • Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing. • Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation. • Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT. ”
Source location
Heather FINDLAY · 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
Review the Trust’s responses and related reports to determine whether further action is needed.

Verbatim wording from the response
“I do however take the concerns raised seriously, and I thank you for bringing them to my attention, together with the other Reports to Prevent Future Deaths you highlight concerning the care of other patients at the Trust. I have asked that NHS England is sighted on the Trust’s response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident Review Report on this matter and note that they have taken a learning to ensure that the police are provided with a direct dial number whenever reporting a patient absconding, which did not happen in this case.”

Source location
Response from NHS England
Page 1 · response
Published 22 June 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
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

Verbatim wording from the response
“The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

Source location
Response from NHS England
Page 1 · response
Published 22 June 2023
Open published response
8 Jun2023
North West Wales
Concerns raised1
1. Delays in completing and sharing investigations into deaths
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the incident process to improve incident handling and learning.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Implement rapid learning panels and incident learning panels.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.
  Stated by Betsi Cadwaladr University LHBStated in progress
AI-generated summary

Eifion Wyn Huws · 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

Eifion Wyn Huws, aged 63, died by suicide at his daughter’s home on 10 June 2022 after being found suspended by a ligature. Concerns included the Emergency Department not having access to a very urgent mental-health referral held in hard-copy notes, and delays in completing and sharing the Health Board’s investigation and implementing resulting actions.

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 completing and sharing investigations into deaths
Wider context from the report
“2. An investigation was commenced by the Health Board into Eifion’s death which appears to have been concluded in July 2022 but did not appear to be finalised and ready for sharing / disseminating until March 2023. I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations, specifically in relation to investigations from deaths in 2020 and 2021. Whilst I have previously been advised of improvements into investigation processes in respect of more recent deaths the issue of timeliness remain. Eifion died in 2022 and yet the time it took for the investigation to be completed and shared, with actions undertaken has been too long. I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner. ”
Source location
Eifion Wyn Huws · 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 incident process to improve incident handling and learning.

Verbatim wording from the response
“In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.”

Source location
Response from Betsi Cadwaladr University Local Health Board
Page 2 · response
Published 12 June 2023
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
Implement rapid learning panels and incident learning panels.

Verbatim wording from the response
“In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.”

Source location
Response from Betsi Cadwaladr University Local Health Board
Page 2 · response
Published 12 June 2023
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
Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.

Verbatim wording from the response
“In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.”

Source location
Response from Betsi Cadwaladr University Local Health Board
Page 2 · response
Published 12 June 2023
Open published response
6 Jun2023
Milton Keynes
Concerns raised1
1. Failure of incident investigations to provide detailed, evidence-challenging analysis
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The patient's 9 July presentation was not typical for peritonitis, making the criticism of the diagnostic approach less clear-cut.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
AI-generated summary

Alexander Shone BLEWITT · 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

Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

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 incident investigations to provide detailed, evidence-challenging analysis
Wider context from the report
“[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival. ”
Source location
Alexander Shone BLEWITT · Prevention of Future Deaths report
Page 2 · 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 patient's 9 July presentation was not typical for peritonitis, making the criticism of the diagnostic approach less clear-cut.

Verbatim wording from the response
“Incident Investigation Reports are reviewed through a weekly meeting (Serious Incident Review Group, SIRG) where there is some consistency of senior membership. This report was signed off by that group. The two key deficiencies which you infer were: acceptance of the diagnostic approach taken on 09 July; and identification of the issue of poor documentation on 11 July without further exploration of root causes or learning. Whilst I would accept both criticisms to a degree, I do not think they are as clear cut as your Regulation 28 Report implies. The 09 July presentation was not typical for peritonitis, although there were also several elements which cast some doubt over the putative diagnosis of urinary tract infection.”

Source location
Response from Milton Keynes University Hospitals
Page 5 · response
Published 23 June 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Investigation reports containing conflicting evidence

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to investigate an operating-table death

Concerns raised1

Failure to undertake an adequately scoped serious investigation of community care incidents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to complete serious incident investigations within required timescales

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of Serious Incident investigations to provide robust critical analysis and identify learning for patient safety

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to review relevant care notes during incident investigations

Concerns raised2

Failure to promptly obtain, secure and preserve relevant serious-incident evidence

Actions described in response 1

Actions described in response 6

Respondent positions 1

Actions described in response 8

Respondent positions 1

Actions described in response 2

Respondent positions 1