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.

17 Jul2022
Manchester South
Concerns raised1
1. Failure to identify incident learning from what went wrong
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 4
1. Action
  Complete a retrospective multidisciplinary learning review of the incident and identify learning from the case.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
3. Action
  Review the Incident Reporting and Incident and Complaint Investigation Policy against the NHS England Patient Safety Framework.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
1. Action
  Hold a multidisciplinary learning event and share learning from the case to support prevention of harm and improve future patient experience.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustNo action considered necessary
AI-generated summary

Kathleen Stewart · 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

Kathleen Stewart fell at her care home and was taken to hospital after reporting groin pain. Her pelvic X-ray was later reported as showing a minimally displaced fracture, but the report was not acted upon; she was discharged without the indicated follow-up and subsequently deteriorated and died. The concerns included the failure to act on the abnormal imaging report and the lack of a specific investigation into the incident and related systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify incident learning from what went wrong
Wider context from the report
“1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:- a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging. ”
Source location
Kathleen Stewart · 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
Complete a retrospective multidisciplinary learning review of the incident and identify learning from the case.

Verbatim wording from the response
“As a result of your concerns outlined above, the Trust has undertaken a retrospective concise investigation into Mrs Stewart’s case in the form of an Multi Disciplinary Team (MDT) learning review involving Urgent Care and Radiology.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022
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
Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.

Verbatim wording from the response
“In addition to this, a planned monthly focus on incident reporting is currently underway across the organisation and being led by the Assistant Director of Integrated Governance throughout September, culminating in the Trust’s Patient Safety Conference on October 6th 2022. This programme of events and activities seeks to engage staff at all levels and focuses on identification of incidents or near misses, incident reporting, acting on and learning from incidents.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Incident Reporting and Incident and Complaint Investigation Policy against the NHS England Patient Safety Framework.

Verbatim wording from the response
“It is considered that this could have been handled differently, with improved triangulation. Detailed action to improve this have been outlined to you in my letter of 11th August 2022 and you are aware that the Trust’s Incident Reporting, and Incident and Complaint Investigation Policy is currently being reviewed alongside the NHS England Patient Safety Framework to ensure that this aligns. The policy will outline the process for identifying, reporting, managing, investigating and learning from patient safety incidents. The purpose of this review of policy is to support a systematic, compassionate and effective response to patient safety incidents; with a clear focus on learning and continuous improvement. This work will ensure accountability, compassion, openness and ownership of improvement and will provide a basis for local training and development.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022
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 a multidisciplinary learning event and share learning from the case to support prevention of harm and improve future patient experience.

Verbatim wording from the response
“I hope that this provides you with assurance that this matter has been taken seriously with a commitment to improve and learn from these events. In addition to this, in September 2022, Mrs Stewart’s case will form part of a multidisciplinary learning event being held by the Trust. We will seek to share the learning from Mrs Stewart’s case in order to prevent harm to, and improve the experience of, future patients. Inevitably, this will include a focus on incident reporting, which supports our aims outlined earlier in this letter.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 27 September 2022
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 incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.

Verbatim wording from the response
“The MDT learning panel noted that a review of Mrs Stewart’s care by the Learning from Deaths Team was undertaken in December 2021. The Learning from Deaths Team identified concerns that the family and care home had not been informed of the fractured pubic rami and an incident form was completed, in accordance with Trust guidelines. At that time, work was ongoing to improve results governance within the organisation; with collaboration between Urgent Care, Radiology and the Clinical Information Team. There was a risk on the Urgent Care Risk Register in relation to results governance, with mitigation and further action recorded. Following a discussion with the Emergency Department’s Clinical Director, the incident was closed, with no further action identified. It is apparent that operational pressures as a result of our Covid-19 response impacted upon our oversight of this.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022
Open published response
1 Jul2022
Manchester City
Concerns raised1
1. Failure of serious incident investigations to obtain relevant information and make additional enquiries
This report raised 13 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

Shona Christine Michaela Campbell · 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

Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the 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 obtain relevant information and make additional enquiries
Wider context from the report
“10. The opportunities missed by the Safety Matters Ltd Serious Incident Investigation report process to obtain other relevant information and/or make additional enquiries which could affect the overall findings and recommendations for learning, improving practice and procedures as well as patient safety. This will also help improve other investigations that the authors of the report may do in the future. ”
Source location
Shona Christine Michaela Campbell · Prevention of Future Deaths report
Page 6 · concerns
Open source report
22 Jun2022
Manchester South
Concerns raised1
1. Failure to conduct prompt, rigorous and effective investigations of clinical 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 15
1. Action
  Deliver comprehensive root cause analysis investigation training for relevant clinical and corporate staff.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
2. Action
  Maintain a live register of staff who have completed root cause analysis investigation training.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
3. Action
  Disseminate a briefing on triangulation and factual accuracy in investigations across the Trust.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
1. Action
  Provide the updated investigator toolkit to each root cause analysis investigation team.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
2. Action
  Require appropriate Matron review and approval of investigations through the revised Safer Care Assurance Process.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
3. Action
  Require review of root cause analysis requests by senior nursing and governance leaders when a patient dies during investigation.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
4. Action
  Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
5. Action
  Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
6. Action
  Conduct ongoing local audits to monitor adherence to the complaints and investigation policy.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
7. Action
  Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
8. Action
  Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
9. Action
  Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
10. Action
  Quality-assess falls-pathway investigations against clinical and nursing records before assurance-panel review.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
11. Action
  Implement Trust-wide witness statement training and develop supporting statement templates.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
12. Action
  Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustUnable to act
AI-generated summary

Derek Holmes · 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

Derek Holmes, who had advanced metastatic prostate cancer and congestive cardiac failure, was admitted to hospital with several acute problems and fell while attempting to get out of bed. He sustained a left hip fracture requiring surgery and died after developing vomiting and signs of a chest infection. Concerns included errors in the Trust’s Root Cause Analysis, inadequate formal examination of issues including patient call-bells and delays in obtaining specialist advice, and the grading of the fall’s harm.

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 conduct prompt, rigorous and effective investigations of clinical incidents
Wider context from the report
“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”
Source location
Derek Holmes · 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
Deliver comprehensive root cause analysis investigation training for relevant clinical and corporate staff.

Verbatim wording from the response
“The Trust recognise the importance of comprehensive investigation training to underpin the methodology and rigor that must be applied to this process. As such, the Trust are providing root cause analysis investigation training days which commence in September 2022, and”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 1 · response
Published 22 September 2022
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
Maintain a live register of staff who have completed root cause analysis investigation training.

Verbatim wording from the response
“The training has been targeted initially to key members of clinical and corporate teams who are likely to undertake root cause analysis or complaints investigations as part of their role. Once undertaken the Integrated Governance Team will hold a live register of staff who have completed root cause analysis investigation training. This is to ensure that on the commissioning of any new investigation, at least one member of the team has completed this training.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022
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
Disseminate a briefing on triangulation and factual accuracy in investigations across the Trust.

Verbatim wording from the response
“The Trust has used the case of Mr Holmes and subsequent learning to develop a seven minute briefing which has been shared widely across the Trust, to reemphasise the importance of triangulation and accuracy of data used within any investigations including root cause analysis and complaints.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022
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 the updated investigator toolkit to each root cause analysis investigation team.

Verbatim wording from the response
“Overseen by the Head of Investigations, Learning and Audit a resource tool kit for investigators has been reviewed an updated to include guidance on triangulation, factual accuracy and a data mapping tool which should be included as part of the investigation process. The tool kit will be provided to each investigation team at the commencement of a root cause analysis investigation.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022
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
Require appropriate Matron review and approval of investigations through the revised Safer Care Assurance Process.

Verbatim wording from the response
“In regard to the errors identified within the root cause analysis, steps have been taken following the inquest of Mr Holmes to strengthen the process in which these documents are checked for quality and factual accuracy, with increased divisional ownership and oversight. The Safer Care Assurance Process has been revised to explicitly include the expectation for all investigations of this form to be reviewed and approved as an accurate account of the incident and learning by an appropriate Matron. Although it is not possible to completely remove the human factors which can affect this process, it is anticipated that this should reduce the opportunity for errors such as those identified in the root cause analysis document presented in relation to Mr. Holmes.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022
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
Require review of root cause analysis requests by senior nursing and governance leaders when a patient dies during investigation.

Verbatim wording from the response
“In addition to this, the Safer Care Assurance Process also includes a caveat that the request for root cause analysis is reviewed by the Head of Nursing and Assistant Director of Integrated Governance should the patient die during the investigation process. This is intended to provide an opportunity to stop and reassess whether continuation of the enquiries is the most appropriate cause of action, or whether an additional or more comprehensive form of investigation is required.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.

Verbatim wording from the response
“Prior to the inquest of Mr Holmes, I had instructed a review of the Trust’s Incident Reporting and Incident and Complaints Investigation Policy. This was in the context of Patient Safety 2, as information and resources become available to inform the Trust approach. The learning from this inquest has further informed the quality assurance process. The review and update to the Policy has been undertaken by the Head of Investigations, Learning and Audit and Head of Nursing for Professional Standards and Assurance, overseen by the Assistant Director of Integrated Governance.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022
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
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.

Verbatim wording from the response
“The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022
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
Conduct ongoing local audits to monitor adherence to the complaints and investigation policy.

Verbatim wording from the response
“The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022
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 bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.

Verbatim wording from the response
“The Trust has also introduced a bimonthly oversight meeting for triangulation of scheduled and new inquests with existing or newly instructed investigatory processes, with Head of Investigations, Audit and Learning, Head of Assurance, Compliance and Governance, Head of Nursing for Professional Standards and Assurance and Legal Services Manager, chaired by the Assistant Director of Integrated Governance. This process has sought to ensure the improved triangulation of current investigations and support early identification of any changes in status to the patient (such as their death) or delays in conclusion. Patient tracking list methodology will be used to inform this process and ensure that there is oversight of all learning activity associated with investigations and inquests.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 22 September 2022
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
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.

Verbatim wording from the response
“The development of a clinical review process is ongoing at the time of preparing this response to ensure that all incident investigations, inquest statements and reviews undertaken as part of our learning from deaths process are assessed and considered cohesively before an inquest. This aims to ensure consistency across all streams of investigation and learning and will help provide an additional clinical check to ensure that any potential discrepancies are responded to, enhancing our approach to learning.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022
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
Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.

Verbatim wording from the response
“The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022
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
Quality-assess falls-pathway investigations against clinical and nursing records before assurance-panel review.

Verbatim wording from the response
“The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022
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 Trust-wide witness statement training and develop supporting statement templates.

Verbatim wording from the response
“Beyond this, to further strengthen internal processes, the Trust are undertaking training to support the development of staff. Witness statement training is being implemented Trust wide to help support those who have been approached to prepare statements. Clinical and nursing staff understand that they may be asked to provide a written report about their involvement in a patient’s care. The training will accentuate that the statement is to focus on the facts relevant to death and is to be detailed and accurate. In order to maintain consistency, templates are being drafted to ensure structure is provided.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 6 · response
Published 22 September 2022
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 strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.

Verbatim wording from the response
“To provide an additional safety net in this process, the Trust has also taken steps to amend and improve the triage system for newly listed inquests. In the context of the recent letter HM Senior Coroner received from Mr Richard Jolly of Weightmans LLP, in relation to the provision of our inhouse legal team, processes have been reinvigorated to ensure triage, review and instruction sent out to clinicians within seven days of the initial inquest request.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 7 · response
Published 22 September 2022
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
Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.

Verbatim wording from the response
“Whilst basic training has been provided for Trust members of staff in incident management over the last two years and support has been offered, and comprehensive, individual and bespoke support has been provided to individuals completing investigations, the delivery of largescale comprehensive investigation training has been challenging in the context of Covid and the Covid response. The reasons for this are twofold; both in terms of the redeployment of key members of the corporate governance team to support clinical areas, and in terms of the ability of staff to attend, when the training is not mandatory.”

Source location
Response from NHS Tameside and Glossop Integrated Care
Page 1 · response
Published 22 September 2022
Open published response
17 Jun2022
Avon
Concerns raised1
1. Inadequate investigation of incidents
This report raised 1 other concern. 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 5
1. Action
  Complete a second significant event analysis using the revised investigation system.
  Stated by Air Balloon SurgeryStated completed
2. Action
  Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.
  Stated by Air Balloon SurgeryStated completed
3. Action
  Undertake a root cause analysis with detailed risk assessment to identify safety actions.
  Stated by Air Balloon SurgeryStated completed
1. Action
  Produce and use a new significant event analysis policy and documentation process for future investigations.
  Stated by Air Balloon SurgeryStated completed
2. Action
  Review the new significant event analysis system at the practice board meeting after its further use in August.
  Stated by Air Balloon SurgeryStated planned
Respondent positions 1
1. Position
  Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.
  Stated by Air Balloon SurgeryExisting arrangements considered sufficient
AI-generated summary

Donald Gore · 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

Donald Gore acquired a Mycobacterium Chimaera infection during open-heart surgery in November 2016 and died after a prolonged delay in diagnosis. The report describes failures to communicate and recognise the infection risk, delays in testing, and treatment for misdiagnosed sarcoidosis. It also raises concerns that the investigation into the incident was inadequate and was not disclosed to the Coroner’s office.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate investigation of incidents
Wider context from the report
“The evidence demonstrated that the General Practitioner to whom Mr Gore first presented with symptoms on 3.11.17 did not read the alert regarding the risk of Mycobacterium Chimaera infection contained in his GP records, entered in March 2017 further to a letter sent to the practice by the cardiac surgery department. The investigation in response to this is summarised in a document headed “Proforma for completion at SEA/adverse incident meeting” dated 14.1.19. My concerns are - 1. The investigation in response to this incident summarised in that document – a) Does not conform to the usual detail and format of such investigations (eg a Root Cause Analysis), and b) Appeared inadequate; (In addition the investigation and document, or even their existence, were not disclosed to the Coroner’s office despite three GP statements/reports from your practice being requested and provided in the preparation for the Inquest, only being revealed in the course of oral evidence from the GP during the course of the Inquest). ”
Source location
Donald Gore · 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
Complete a second significant event analysis using the revised investigation system.

Verbatim wording from the response
“3. Additionally, the surgery has completed a second SEA process on the 18th July 2022 regarding this incident. This is attached and has identified the following:”

Source location
Response from Air Balloon Surgery
Page 2 · response
Published 20 September 2022
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
Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.

Verbatim wording from the response
“1. The surgery is fully committed to openness and promoting a learning and improving culture. We have carefully considered the benefits of external scrutiny to help us see beyond any “organisational blind spots” and have appointed an experienced objective external GP and GP Appraiser, who has never worked for the surgery and has knowledge of local systems.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
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
Undertake a root cause analysis with detailed risk assessment to identify safety actions.

Verbatim wording from the response
“2. Undertaken a Root Cause Analysis – attached. This has included a detailed risk assessment showing how rare this infection is and has helped to identify actions for the surgery.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
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
Produce and use a new significant event analysis policy and documentation process for future investigations.

Verbatim wording from the response
“5. Produced a new SEA policy and documentation process. CQC have been given a copy. We feel our new policy and documentation is robust and will result in a better investigation, including risk assessing, analysis, outcome, and written record.”

Source location
Response from Air Balloon Surgery
Page 4 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the new significant event analysis system at the practice board meeting after its further use in August.

Verbatim wording from the response
“6. The surgery has used this new system for the repeat SEA conducted on this case on the 18th July 2022. Attached. We will continue to use it for a further SEA meeting planned in August, where other SEA issues are being discussed. The practice board will then review at its meeting in August to assess if it is fit for purpose.”

Source location
Response from Air Balloon Surgery
Page 4 · response
Published 20 September 2022
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
Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.

Verbatim wording from the response
“3. We have reviewed what our regulatory body- CQC- required in terms of investigation and managing incidents. This indicated that the main approach is SEA. GP mythbuster 3: Significant event analysis (SEA) – Care Quality Commission (cqc.org.uk) There is no specific mention of Root Cause Analysis on the website and this is not a technique which is generally used in general practice.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
Open published response
8 Jun2022
Birmingham and Solihull
Concerns raised2
1. Failure of investigations to examine relevant clinical care and record conclusions and their basis
2. Failure of serious incident investigations to identify relevant guidance and explain departures from it
This report raised 2 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 4
1. Action
  Require investigators to use comprehensive literature and independent evidence reviews and address families’ concerns in investigation reports.
  Stated by Worcestershire Acute Hospitals NHS TrustStated in progress
2. Action
  Complete a gap analysis of national patient-safety investigation standards against current practice.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
3. Action
  Develop revised investigation processes, report templates and investigator guidance informed by the standards gap analysis.
  Stated by Worcestershire Acute Hospitals NHS TrustStated in progress
1. Action
  Raise investigators’ awareness of Library Services support for searches of clinical guidelines and publications.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
AI-generated summary

Jack HURN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jack Hurn, aged 26, died after developing vaccine-induced immune thrombocytopenia and thrombosis with cerebral venous sinus thrombosis following an AstraZeneca COVID-19 vaccination. Concerns included the absence or non-use of guidance and pathways for timely specialist management of VITT, aspects of his care at Alexandra Hospital, and the apparent inadequacy of the investigation into his 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
Failure of investigations to examine relevant clinical care and record conclusions and their basis
Wider context from the report
“1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB. - The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT). - Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission. 2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination: i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021 ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021 iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021 3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital. 4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case. 5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions. 6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients. 7. No adequate explanation was given in evidence to explain why the investigation was incomplete. 8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk. ”
Source location
Jack HURN · 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 of serious incident investigations to identify relevant guidance and explain departures from it
Wider context from the report
“1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB. - The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT). - Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission. 2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination: i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021 ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021 iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021 3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital. 4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case. 5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions. 6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients. 7. No adequate explanation was given in evidence to explain why the investigation was incomplete. 8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk. ”
Source location
Jack HURN · 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
Require investigators to use comprehensive literature and independent evidence reviews and address families’ concerns in investigation reports.

Verbatim wording from the response
“We are ensuring investigators undertake more comprehensive literature and independent evidence reviews when indicated, rather than relying on internal expertise, and ensure that the concerns of patient’s family are sought and addressed in our reports. As part of our reflection we have recognised the need and actioned raising awareness of the Trust’s Library Services who can support literature searches for existing clinical guidelines and publications, to our investigators.”

Source location
Response from NHS Worcestershire Acute Hospital
Page 2 · response
Published 16 September 2022
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 a gap analysis of national patient-safety investigation standards against current practice.

Verbatim wording from the response
“You may also be aware that NHS England is due to publish their Patient Safety Incident Response Framework (PSIRF), which describes how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Included as part of the framework are the National Standards for Patient Safety Investigation, published in 2020, designed to support improvement in the quality of patient safety investigation in NHS-funded care and specifies the basic requirements of reviews. The Trust completed a gap analysis of these standards against current practice, which is being used to inform the development of a revised investigation processes and report template as well as guidance for investigators. The Framework supports the National Patient Safety Strategy, to improve understanding of safety by drawing insights from patient safety incidents.”

Source location
Response from NHS Worcestershire Acute Hospital
Page 2 · response
Published 16 September 2022
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
Develop revised investigation processes, report templates and investigator guidance informed by the standards gap analysis.

Verbatim wording from the response
“You may also be aware that NHS England is due to publish their Patient Safety Incident Response Framework (PSIRF), which describes how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Included as part of the framework are the National Standards for Patient Safety Investigation, published in 2020, designed to support improvement in the quality of patient safety investigation in NHS-funded care and specifies the basic requirements of reviews. The Trust completed a gap analysis of these standards against current practice, which is being used to inform the development of a revised investigation processes and report template as well as guidance for investigators. The Framework supports the National Patient Safety Strategy, to improve understanding of safety by drawing insights from patient safety incidents.”

Source location
Response from NHS Worcestershire Acute Hospital
Page 2 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise investigators’ awareness of Library Services support for searches of clinical guidelines and publications.

Verbatim wording from the response
“We are ensuring investigators undertake more comprehensive literature and independent evidence reviews when indicated, rather than relying on internal expertise, and ensure that the concerns of patient’s family are sought and addressed in our reports. As part of our reflection we have recognised the need and actioned raising awareness of the Trust’s Library Services who can support literature searches for existing clinical guidelines and publications, to our investigators.”

Source location
Response from NHS Worcestershire Acute Hospital
Page 2 · response
Published 16 September 2022
Open published response
25 May2022
East London
Concerns raised1
1. Failure to investigate unexpected care-impacting events through Serious Incident Investigation
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.
Respondent positions 1
1. Position
  The incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustDisputes the concern
AI-generated summary

Elizabeth Margaret Mills · 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

Elizabeth Margaret Mills was admitted to hospital with abdominal pain on 25 March 2021, underwent surgery for a perforated pyloric ulcer, and later developed pneumonia requiring increasing oxygen therapy. She died after removing an oxygen mask while unattended in a side ward, when nasal cannulae were replaced but were no longer connected to an oxygen supply. Concerns included poor medical record-keeping about the do-not-attempt-CPR process, reliance on her husband to keep the mask in place, and the Trust’s failure to investigate unexpected events through a 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 to investigate unexpected care-impacting events through Serious Incident Investigation
Wider context from the report
“3. Unexpected events that impacted upon Mrs Mills’ care were not investigated by the Trust in the form of a Serious Incident Investigation. ”
Source location
Elizabeth Margaret Mills · 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 incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.

Verbatim wording from the response
“The incident was reported on 26 March 2021 and it was flagged as a potential SI matter by the Quality and Safety ‘Q&S’ Team. A review was undertaken by the ED Matron and by the Surgical Division. This was held with multidisciplinary key stakeholders from including pharmacists, matrons, registrars, clinical leads, consultants and consultant surgeons from Gastroenterology, Breast and General Surgery, Adult Day Unit and Theatres. The reviews established that the correct morphine doses were given to EM at appropriate times and the matter was not an SI matter. The Q&S team removed the potential SI flag. Separately, EM’s husband pursued a complaint regarding her care and management which was not upheld and the husband declined a meeting with the Trust.”

Source location
Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022
Open published response
18 May2022
Surrey
Concerns raised1
1. Failure to investigate and review deaths for learning and implementation of necessary changes
This report raised 11 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 5
1. Action
  Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
  Stated by NHS EnglandStated planned
2. Action
  Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.
  Stated by NHS Frimley ICBStated planned
3. Action
  Conduct a significant event analysis of the death with clinical staff and review the resulting learning and actions.
  Stated by Farnham Park Health Group and Recipient name withheldStated completed
1. Action
  Share the significant event analysis findings with practice staff, the CCG and CQC.
  Stated by Farnham Park Health Group and Recipient name withheldStated completed
2. Action
  Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.
  Stated by Farnham Park Health Group and Recipient name withheldStated planned
Respondent positions 6
1. Position
  NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
  Stated by NHS EnglandRedirects responsibility
1. Position
  The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
  Stated by Care Quality CommissionDisputes the concern
2. Position
  No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
3. Position
  The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
  Stated by General Medical CouncilDisputes the concern
4. Position
  No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
  Stated by General Medical CouncilNo action considered necessary
5. Position
  The Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.
  Stated by Farnham Park Health Group and Recipient name withheldDisputes the concern
AI-generated summary

Matthew John Evans · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.

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 and review deaths for learning and implementation of necessary changes
Wider context from the report
“2. The actions of the General Practice No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice. ”
Source location
Matthew John Evans · 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
Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.

Verbatim wording from the response
“This report will be provided to the Regional Mortality Boards so that they may share it with all ICBs to ensure that they are able to learn from this event.”

Source location
Response from NHS England
Page 5 · response
Published 19 May 2022
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
Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.

Verbatim wording from the response
“Practices will also be reminded of the importance of completing Serious Event Audits for serious/unexpected incidents. The NHS Frimley ICB quality team will be requesting the Serious Event Audits from practices as part of the investigation into suicides recorded as part of the NHSE”

Source location
Response from NHS Firmley
Page 1 · response
Published 19 May 2022
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
Conduct a significant event analysis of the death with clinical staff and review the resulting learning and actions.

Verbatim wording from the response
“3. The Partners at the Practice were awaiting the outcome of the Inquest before undertaking a Serious Event Audit (“the SEA”). The Practice Partners considered it appropriate that the SEA took place when it was possible to maximize the number of clinicians attending the audit meeting. The Practice conducted a SEA on Tuesday 31 May 2022. There having been delays due to bereavement, sickness, leave and the various Bank Holidays which interrupted the Practice working timetable, which impacted on the availabilities of the various members of Practice team. Six clinicians participated in the SEA, including ████████.”

Source location
Response from Farnham Practice
Page 1 · response
Published 19 May 2022
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
Share the significant event analysis findings with practice staff, the CCG and CQC.

Verbatim wording from the response
“44. The Practice has shared the findings of the SEA with all staff at the practice, the CCG and CQC.”

Source location
Response from Farnham Practice
Page 6 · response
Published 19 May 2022
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
Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.

Verbatim wording from the response
“45. Going forward, as part of the Practice’s Clinical Governance Policy, it was further agreed that unexpected deaths will be discussed at the Practice Clinical Meetings’ Meetings which are held every week and attended by the GP clinicians and Partners.”

Source location
Response from Farnham Practice
Page 6 · response
Published 19 May 2022
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
NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.

Verbatim wording from the response
“c) Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.”

Source location
Response from NHS England
Page 4 · response
Published 19 May 2022
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 circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.

Verbatim wording from the response
“We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where”

Source location
Response from Care Quality Commisson
Page 1 · response
Published 19 May 2022
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
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.

Verbatim wording from the response
“We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where”

Source location
Response from Care Quality Commisson
Page 1 · response
Published 19 May 2022
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 concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.

Verbatim wording from the response
“The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.”

Source location
Response from General Medical Council(2)
Page 1 · response
Published 19 May 2022
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
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.

Verbatim wording from the response
“The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.”

Source location
Response from General Medical Council(2)
Page 1 · response
Published 19 May 2022
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 Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.

Verbatim wording from the response
“Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.”

Source location
Response from Farnham Practice
Page 5 · response
Published 19 May 2022
Open published response
15 May2022
Surrey
Concerns raised3
1. Delayed and incomplete serious incident investigations
2. Lack of openness, transparency and proper investigation of deaths
3. Failure to undertake prompt internal enquiries after sudden unexpected deaths
This report raised 10 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 7
1. Action
  Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.
  Stated by Care Quality CommissionStated completed
2. Action
  Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
  Stated by NHS EnglandStated completed
3. Action
  Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
  Stated by NHS EnglandStated completed
1. Action
  Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
  Stated by The Children's TrustStated in progress
2. Action
  Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
  Stated by The Children's TrustStated completed
3. Action
  Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
  Stated by The Children's TrustStated completed
4. Action
  Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
  Stated by The Children's TrustStated planned
Respondent positions 2
1. Position
  Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
1. Position
  Current leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
AI-generated summary

Connor Samuel Timothy Wellsted · 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

Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.

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Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delayed and incomplete serious incident investigations
Wider context from the report
“3. Probity and Investigation by the Children’s Trust, Tadworth The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed. Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death. The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant. ”
Source location
Connor Samuel Timothy Wellsted · 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 openness, transparency and proper investigation of deaths
Wider context from the report
“4. Senior management, Children’s Trust, Tadworth The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust. As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency. ”
Source location
Connor Samuel Timothy Wellsted · 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
Failure to undertake prompt internal enquiries after sudden unexpected deaths
Wider context from the report
“3. Probity and Investigation by the Children’s Trust, Tadworth The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed. Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death. The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant. ”
Source location
Connor Samuel Timothy Wellsted · 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
Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.

Verbatim wording from the response
“All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.”

Source location
Response from CQC
Page 4 · response
Published 17 May 2022
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 the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.

Verbatim wording from the response
“In terms of investigation, the NHS England Patient Safety Incident Response Framework in July 2022. The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract, and as such is mandatory for services provided under that contract and will include Providers such as The Children’s Trust at Tadworth Court.”

Source location
Response from NHS England
Page 2 · response
Published 17 May 2022
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
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.

Verbatim wording from the response
“I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.”

Source location
Response from NHS England
Page 2 · response
Published 17 May 2022
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
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.

Verbatim wording from the response
“In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.”

Source location
Response from The Children's Trust
Page 8 · response
Published 17 May 2022
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
Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.

Verbatim wording from the response
“We accept that we should have thoroughly examined the potential role of the cot bumper in our initial investigation. With hindsight we were too quick to rule the bumper out based on the post-mortem findings. Our learnings here are reflected in the updates we have since made to our “Incident Reporting and Investigation, including Duty of Candour Policy”.”

Source location
Response from The Children's Trust
Page 9 · response
Published 17 May 2022
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
Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.

Verbatim wording from the response
“Our Basic Life Support (BLS) training follows the Resuscitation Council UK guidelines and is mandatory for all nursing and care staff. Shift leaders and senior nurses also attend an enhanced BLS+ training annually which is designed to increase knowledge, skills and confidence in managing medical emergencies. It further emphasises and builds upon the Resuscitation Council UK guidelines taught in BLS and includes enhanced simulations and training around escalation of care and management of medical emergencies more relevant to our service. Additionally, the training covers how to call for help, using the bleep system, using call bells, dialling 999 and at what point each might be appropriate. Each BLS session ends with a mandatory assessment of skills.”

Source location
Response from The Children's Trust
Page 8 · response
Published 17 May 2022
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 simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.

Verbatim wording from the response
“In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.”

Source location
Response from The Children's Trust
Page 8 · response
Published 17 May 2022
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
Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.

Verbatim wording from the response
“All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.”

Source location
Response from CQC
Page 4 · response
Published 17 May 2022
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 leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.

Verbatim wording from the response
“The inspections completed in the five years since Connor’s death, as well as the information available regarding TCT’s response to incidents, events and complaints, have all identified safe practice and good leadership and governance. The CQC have not found any evidence to suggest that the concerns raised in the Regulation 28 report, remain as concerns, regarding current leadership, governance or practice.”

Source location
Response from CQC
Page 5 · response
Published 17 May 2022
Open published response
19 Apr2022
Surrey
Concerns raised1
1. Failure to investigate wider circumstances of serious 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.

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

Volodymyr KOROL · 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

Volodymyr Korol died from a fatal ventricular arrhythmia in his bedroom at Shrewsbury Court Independent Hospital on 1 August 2020, following cardiac and other physical health conditions. The inquest identified concerns including failures to assess his capacity regarding weight management, investigate and manage cardiac and other physical health conditions, share medical information, and escalate abnormal vital signs. The Coroner was concerned that similar practices might be present at another site operated by Whitepost Healthcare Group.

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 wider circumstances of serious incidents
Wider context from the report
“Following Mr Korol’s death Shrewsbury Court Independent Hospital did not declare a Serious Incident. As such, whilst there was a 72 hour serious incident review into the events of 31 July and 1 August 2020, there was no investigation into the wider circumstances leading up to his death. Accordingly, none of the matters which form part of the jury’s narrative conclusion were identified by Shrewsbury Court Independent Hospital either at the time as part of their own internal investigation or thereafter as part of their preparation for the inquest. The court heard evidence that Shrewsbury Court Independent Hospital has now closed down but that Whitepost Healthcare Group continues to operate one other site, namely Iden Manor Nursing Home in Kent. The jury found that there were a number of causative failures in relation to the carrying out of mental capacity assessments, the sharing of medical information with other agencies and the appropriate escalation of vital signs which fall outside of normal parameters. All of these issues are equally as important in nursing homes as they are in psychiatric hospitals. Given that these issues were not identified and acted upon by Whitepost Healthcare Group at any point prior to the inquest, the Coroner is concerned that similar practices may be present at Iden Manor Nursing Home in Kent, which would present a risk of future deaths. In the circumstances the Coroner considers that practices should be audited at Iden Manor Nursing Home to ensure that the deficient practices identified by the jury in relation to Mr Korol’s care at Shrewsbury Court Independent are not present at Iden Manor Nursing Home. ”
Source location
Volodymyr KOROL · Prevention of Future Deaths report
Page 7 · concerns
Open source report
11 Apr2022
Norfolk
Concerns raised5
1. Failure to investigate the source and nature of a hazardous item after an incident
2. Inaccuracies in patient safety incident investigation reports
3. Failure to interview relevant staff during patient safety investigations
1. Delays in completing and providing patient safety incident investigation reports
2. Incident investigations failing to establish the sequence of safety-critical events
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.
Respondent positions 2
1. Position
  Agency staff were not compelled to participate in Trust reviews, preventing interviews with some staff involved in Tracy’s care.
  Stated by Norfolk and Suffolk NHS Foundation TrustUnable to act
1. Position
  The review panel considered accounts from participating staff and professionals sufficient despite some agency staff not being interviewed.
  Stated by Norfolk and Suffolk NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Tracy Dawn WOOD · 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

Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident 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 investigate the source and nature of a hazardous item after an incident
Wider context from the report
“5. Following Tracy ████████ on the evening of 1 June 2021, there was no investigation as to where she obtained the ████████, despite there being a bold, red instruction in the SBAR records that Tracy was not to be given a ████████. By the date of the inquest some witnesses were still unaware as to how Tracy had come by the ████████ with. Some witnesses were still unaware as to what Tracy had used as a ████████ ”
Source location
Tracy Dawn WOOD · 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
Inaccuracies in patient safety incident investigation reports
Wider context from the report
“11. The PSII Report contains many inaccuracies including Tracy’s date of death, stating it to be 5 June 2021. The report refers to Tracy ████████ again at 21:00 on 3rd June 2021. The correct date is the 2 June 2021 ”
Source location
Tracy Dawn WOOD · 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
Failure to interview relevant staff during patient safety investigations
Wider context from the report
“13. The PSII did not involve interviews with members of staff who had involvement with Tracy in the hours and days prior to her death, including staff who gave the ████████ to Tracy and a Nurse who had regular involvement with Tracy’s care and who knew her well ”
Source location
Tracy Dawn WOOD · 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
Delays in completing and providing patient safety incident investigation reports
Wider context from the report
“10. A draft Patient Safety Incident Investigation Report (PSII) has been prepared. Evidence was heard that this is now used rather than a Serious Incident Requiring Investigation Report and has the advantage of being “more timely” and providing more learning. The report was still in draft form at the date of the inquest (nine months following Tracy’s death) and the draft was only available to me on the morning of the first day of the inquest, despite assurances at Pre Inquest Review Hearings that it would be available prior to the inquest. ”
Source location
Tracy Dawn WOOD · 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
Incident investigations failing to establish the sequence of safety-critical events
Wider context from the report
“12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021. The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed. Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed. ”
Source location
Tracy Dawn WOOD · 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
Agency staff were not compelled to participate in Trust reviews, preventing interviews with some staff involved in Tracy’s care.

Verbatim wording from the response
“The staff who were not spoken to were agency staff who are not compelled to comply with Trust reviews despite the obvious ethical and professional drivers to do so. In this review one agency staff member approached did make himself available however a female staff member did not. However, the review panel were content that the staff who did engage knew Tracy well and were able to give a consistent account of events as they knew them, this included a range of professionals: nursing, occupational therapy, psychology, and psychiatry.”

Source location
Response from Hellesdon Hospital
Page 5 · response
Published 26 April 2022
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 review panel considered accounts from participating staff and professionals sufficient despite some agency staff not being interviewed.

Verbatim wording from the response
“The staff who were not spoken to were agency staff who are not compelled to comply with Trust reviews despite the obvious ethical and professional drivers to do so. In this review one agency staff member approached did make himself available however a female staff member did not. However, the review panel were content that the staff who did engage knew Tracy well and were able to give a consistent account of events as they knew them, this included a range of professionals: nursing, occupational therapy, psychology, and psychiatry.”

Source location
Response from Hellesdon Hospital
Page 5 · response
Published 26 April 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to identify incident learning from what went wrong

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.4

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 obtain relevant information and make additional enquiries

Concerns raised1

Failure to conduct prompt, rigorous and effective investigations of clinical 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.15

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

Concerns raised1

Inadequate investigation of 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.5

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

Actions described in response 4

Respondent positions 1

Actions described in response 15

Respondent positions 1

Actions described in response 5

Respondent positions 1