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

Distinct published reports

Individual concerns
316

A report can raise multiple concerns

Date range
2008–2026

First to latest report issue date

Stated actions
447

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social 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.

  1. Avon

    AI-generated summary

    Lesley Julie BRASS · 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

    Lesley Julie BRASS fell at home, sustained a head injury, and was admitted to hospital after her wound became infected. While an inpatient, she developed severe hyperkalaemia but did not receive the required emergency treatment within the specified timeframe, and she suffered a fatal cardiac arrest. The report raises concerns about failures to recognise, escalate and treat the condition, and about the Plastic Surgery department’s subsequent investigation, openness and willingness to acknowledge mistakes.

    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 the Plastic Surgery department to properly investigate serious untoward incidents

    Wider context from the report

    “During the course of the pre-inquest investigation, and at the inquest itself, evidence came to light which led me to conclude that the Trust in general, and the Plastic Surgery department in particular, was/were reluctant to investigate Mrs Brass’s death properly, and to be open about their findings. I am particularly concerned that a number of the consultants from the Plastic Surgery department failed to co-operate with and/or progress the investigation. ”

    Source location

    Lesley Julie BRASS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Surrey

    AI-generated summary

    Theo Benjamin Young · 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

    Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB 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

    Delays in HSIB investigation completion

    Wider context from the report

    “2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further deaths. ”

    Source location

    Theo Benjamin Young · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Restriction of Trust-led investigation during HSIB investigations

    Wider context from the report

    “1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths. ”

    Source location

    Theo Benjamin Young · Prevention of Future Deaths report
    Page 4 · 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

    Advise NHS trusts to complete 72-hour reports for maternity cases eligible for investigation.

    Verbatim wording from the response

    “1. It is HSIB policy that all NHS trusts are advised to complete 72-hour reports for cases that are referred as eligible for investigation. The purpose of this is to ensure that trusts can readily identify immediate safety concerns and take necessary actions while they await the commencement and outcome of HSIB’s more in-depth reviews. Trusts are not mandated to share their 72-hour reports, but many share them with HSIB voluntarily.”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 1 · response
    Published 18 May 2020

    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

    Escalate safety concerns identified during investigations to the relevant Head of Midwifery and Clinical Director.

    Verbatim wording from the response

    “2. To further support trusts with rapidly addressing safety risks in their maternity services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any matters raised through early escalation. Fortnightly written updates are sent to all Trust Heads of Midwifery to provide updates on the progress of HSIB’s local investigations and to seek support with addressing any barriers to progress.”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 2 · response
    Published 18 May 2020

    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

    Send fortnightly written investigation updates to Trust Heads of Midwifery and seek support to address progress barriers.

    Verbatim wording from the response

    “2. To further support trusts with rapidly addressing safety risks in their maternity services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any matters raised through early escalation. Fortnightly written updates are sent to all Trust Heads of Midwifery to provide updates on the progress of HSIB’s local investigations and to seek support with addressing any barriers to progress.”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 2 · response
    Published 18 May 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing 72-hour reviews, safety escalations, trust engagement and thematic reviews were considered sufficient to support timely risk identification and action.

    Verbatim wording from the response

    “HSIB places utmost importance on the need to ensure that rapid learning takes place for cases that fall within the eligibility criteria of HSIB’s maternity investigation programme. There are several stages throughout HSIB investigations where the opportunity for identifying and addressing safety risks is provided to trusts, and these were implemented during the investigation of baby Theo’s death.”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 1 · response
    Published 18 May 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Regular communication and safety information during investigations were considered sufficient to allow trusts to introduce immediate preventive measures before reports were issued.

    Verbatim wording from the response

    “This report did exceed our target timescale; however, HSIB communicated regularly with SaSH Trust and the family during the investigation process and provided the Trust with relevant safety information. This is a standard process in our investigations as detailed in the response above and enables trusts to introduce any immediately necessary measures to prevent future deaths before the sharing of our report.”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 3 · response
    Published 18 May 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The final report was considered detailed and was shared 14 months after death, not 18 months; most alleged factual errors were rejected.

    Verbatim wording from the response

    “HSIB consider that the report provides detailed reflection of the investigation that was undertaken. Evidence was collated from the medical records, Trust guidelines and policies and interviews with the family and staff (as outlined as requirements in paragraph 3 (3) of the HSIB Maternity Directions 2018).”

    Source location

    2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted
    Page 4 · response
    Published 18 May 2020

    Open published response

  3. Manchester South

    AI-generated summary

    Wayne Lee Millett · 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

    Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.

    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 critically analyse care and treatment against the Care Plan

    Wider context from the report

    “1) The Priory’s own investigation into the circumstances of Mr Millett’s death was notably lacking in meaningful critical analysis of the care and treatment he received, and in particular was fundamentally flawed in that it failed to consider the care given as against the Care Plan despite its obvious central relevance to his death. ”

    Source location

    Wayne Lee Millett · 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

    Recruit a serious incidents investigation officer with a mandate to improve investigation processes.

    Verbatim wording from the response

    “In relation to your concern that we are not a learning organisation, please note we continue to invest significant time and resource in making continuous improvements to the services we provide to some of the most clinically challenging mental health patients in the UK. This includes in relation to incident investigations: in March this year we recruited a highly-experienced serious incidents investigation officer (SIO) with a clear mandate to make improvements to our processes for the benefit of patients and staff including:”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 1 · response
    Published 26 February 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver investigation and report-writing training to senior staff conducting serious incident investigations.

    Verbatim wording from the response

    “• Delivering training to senior staff who are commissioned to complete investigations and prepare reports to ensure they have the necessary skills to identify key issues and convey those concisely and clearly in their written outputs;”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 2 · response
    Published 26 February 2020

    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 staff, including the Group Medical Director and Director of Quality, to review every draft serious incident investigation report.

    Verbatim wording from the response

    “• Strengthening the review process so that all draft serious incident investigation reports are reviewed by a team of senior staff which in all cases includes the Group Medical Director and the Director of Quality.”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 2 · response
    Published 26 February 2020

    Open published response

  4. Manchester City

    AI-generated summary

    Kieran Luke Hubbard · 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

    Kieran Luke Hubbard, who had a history of depressive disorder and recurrent suicidal thoughts, was found dead on 8 February 2019 after hanging himself at a building site. The principal concerns were failures to expedite and properly coordinate an inpatient bed, failures to communicate and escalate the decision to abandon the bed search, inadequate guidance about driving during a mental health crisis, and shortcomings in the post-death 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

    Failures in the post-death investigation process

    Wider context from the report

    “5 6 There were failures in the post death investigation process which may result in the true circumstances not being identified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death ”

    Source location

    Kieran Luke Hubbard · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Andrew Richard Hogg · Prevention of Future Deaths report

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

    Report summary

    Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.

    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 internal investigations into falls

    Wider context from the report

    “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk. In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:- 1. Not all the relevant paperwork was completed following the falls 2. There could have been engagement with other services such as the local falls clinic 3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder” 4. Relevant information should have been updated onto the patient’s electronic record. While I welcome his insightful comments I remain concerned that 1. There was no adequate falls assessment policy 2. There was no obvious escalation pathway following the sequential falls Andrew had 3. There was no internal investigation into any of the falls which occurred 4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision. It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing. While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced. ”

    Source location

    Andrew Richard Hogg · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Birmingham and Solihull

    AI-generated summary

    Andrew Peter Wells · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of robust and effective root cause analysis of serious incidents

    Wider context from the report

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

    Source location

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

    Open source report

  7. Bedfordshire and Luton

    AI-generated summary

    Pamela 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

    Pamela Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s 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 detect significant safety concerns and learning

    Wider context from the report

    “(v)       That points (i)-(iv) had not been detected by the Trust despite its carrying out of a serious incident investigation. I am therefore concerned that significant and potentially life-saving learning may be missed by the Trust in the future even if serious incident investigations are carried out. ”

    Source location

    Pamela Evans · 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 serious incident investigation considered relevant actions and decision-making and did not fall short of its intended purpose.

    Verbatim wording from the response

    “Hospital SI report did not acknowledge or highlight these issues Thank you for drawing my attention to these issues. As you know a serious incident report is to ensure gaps in care, root causes and learning are identified in order to protect future patients and improve our practice.”

    Source location

    2019-0333-Response-by-Bedford-Hospital-NHS-Trust
    Page 3 · response
    Published 10 November 2019

    Open published response

  8. London Inner (West)

    AI-generated summary

    Michael Lobban · 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

    Michael Lobban, who had drug dependency and mental illness, was found dead at home on 23 October 2017 with a significant methadone overdose and other drugs in his body. The report raised concerns about the speed and completeness of Boots’ investigation into missing methadone, the robustness of its controlled-drug audit procedures, and the General Pharmaceutical Council’s reporting and investigative arrangements for discrepancies in controlled drugs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in investigating controlled-drug discrepancies

    Wider context from the report

    “1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through. ”

    Source location

    Michael Lobban · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · 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

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER climbed onto a freight train near Hackney Wick Station in the small hours of 21 March 2019 and were electrocuted. The report identifies concerns about an unrepaired gap in the track perimeter fence, failures to inspect and report it, inadequate internal investigation, and uncertainty about whether there was a national fencing-inspection system failure.

    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

    Inadequacy of internal investigation into fencing inspection system failures

    Wider context from the report

    “Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

    Source location

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · 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

    Investigate nationally whether boundary inspections continue to use dual paper and electronic recording systems.

    Verbatim wording from the response

    “3.1 Network Rail Response-Q3:”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 4 · response
    Published 5 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission a national special-topic audit of compliance with the revised boundary inspection standard for non-tactile forms.

    Verbatim wording from the response

    “new boundary inspection Standard re non-tactile forms will be undertaken by the Network Rail National Audit Team within the next 3 months to identify whether we have a national failure and to what extent.”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 6 · response
    Published 5 November 2019

    Open published response

  10. Inner South London

    AI-generated summary

    Daniel Williams · 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

    Daniel Williams died at St Thomas' Hospital on 26 November 2017 after developing complications of gastrointestinal surgery, including infection and sepsis, against a background of significant medical complexity. Concerns included deficient nursing care on a general gastrointestinal ward and a potential limitation in the investigation of Clostridium difficile cases when a patient had recently been transferred from another ward.

    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 extend C. difficile case investigations to transferring wards

    Wider context from the report

    “4) Although I found at inquest that the presence of c-diff was not relevant to how Mr Williams ultimately came by his death I have residual concerns with the potential under investigation of c-diff cases within the Trust from what I was told about the process which is triggered on discovering the presence of c-diff. 5) At Mr Williams' inquest I was told that c-diff infection is a potentially fatal infection. Consequently it is a regulatory requirement that hospitals trusts carry out a clinical case review whenever c-diff is found in order to determine whether it was linked to any "lapses of care" in the care and treatment of the patients. 6) I was told that what should happen following the collection of a positive sample is that an alert is sent to the infection control nurse when this distributes the mandatory infection control data collection form to, inter alia, the ward on which the patient is currently. That ward - and that ward alone - then investigates focussed on identifying "any significant deviations from best practice..." including in the following categories: deficiency in environmental cleaning, deficiency in hand hygiene and / or deficiency in antimicrobial stewardship. What is not done however, is if the respective patient has recently been transferred from another ward, the investigation does not extend to the conditions on the transferring ward. 7) In this case it was the transferring ward where there were found to have been failings in delivering the fundamentals of care and about which the family had raised significant concerns at the time. The only reason these failures were highlighted was that an investigation was undertaken following a pre-inquest review on 26 September 2018 at which the family raised concerns that Mr Williams had died as a result of a c-diff infection contracted as a result of poor nursing care. The extent of the Trust's investigation was limited as it was conducted significantly after the event. ”

    Source location

    Daniel Williams · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the C. difficile investigation process to assess and investigate relevant prior wards occupied within the preceding seven days.

    Verbatim wording from the response

    “The Trust’s c-diff Action Group, under the chairmanship of Dr Simon Goldenberg, has reviewed the Trust’s c-diff investigation process as a result of Mr Williams’ death.”

    Source location

    2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
    Page 5 · response
    Published 5 November 2019

    Open published response
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Data last updated 7 September 2026