Recurring concern

Inadequate safety incident investigations

Get email alerts

Request correction

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.

25 Sep2025
North Yorkshire and York
Concerns raised3
1. Failure to identify and preserve the accounts of staff directly involved in errors
2. Failure of investigations to identify and question relevant medical team members
3. Delays in commencing investigations and after-action reviews of recognised errors
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Embed the Patient Safety Incident Response Framework within Trust processes.
  Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Pamela Ann HONEYBONE · 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 Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification processes.

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 and preserve the accounts of staff directly involved in errors
Wider context from the report
“3. As a result of the delay at 2 above, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. ”
Source location
Pamela Ann HONEYBONE · 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 investigations to identify and question relevant medical team members
Wider context from the report
“4. Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust investigation focused on nursing involvement with the patients in question and did not seek to identify and question medical team members. ”
Source location
Pamela Ann HONEYBONE · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in commencing investigations and after-action reviews of recognised errors
Wider context from the report
“3. As a result of the delay at 2 above, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. ”
Source location
Pamela Ann HONEYBONE · 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
Embed the Patient Safety Incident Response Framework within Trust processes.

Verbatim wording from the response
“We acknowledge that there was some delay in further investigations being carried out into the circumstances of the radiological error and this meant valuable witness evidence was not included. At the time of Mrs Honeybone’s death the Trust was in the early stages of implementing the Patient Safety Incident Response Framework (PSIRF). This framework is now embedded and if a similar incident occurred it would be likely that a hot debrief or after-”

Source location
Response from York and Scarborough NHS Trust
Page 2 · response
Published 29 September 2025
Open published response
17 Sep2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of independent review of deaths for learning and practice change
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 3
1. Action
  Review the serious incident and identify all associated learning and recommendations.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated planned
3. Action
  Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
Respondent positions 6
1. Position
  The ICB is not responsible for investigating serious incidents involving individual patient care.
  Stated by NHS Surrey and Sussex Integrated Care BoardOutside remit
1. Position
  Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
  Stated by NHS Surrey and Sussex Integrated Care BoardRedirects responsibility
2. Position
  The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
3. Position
  The Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.
  Stated by Sussex Medical ChambersRedirects responsibility
4. Position
  Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
  Stated by Care Quality CommissionOutside remit
5. Position
  The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
  Stated by Care Quality CommissionRedirects responsibility
AI-generated summary

Keith James Hankin · 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

Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.

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 independent review of deaths for learning and practice change
Wider context from the report
“5. Learning from Mr Hankin’s death The ICB did not independently review the circumstances of Mr Hankin’s death to confirm if there was any learning or changes in practice to prevent further deaths. Likewise, SMC relied on ████████ to inform them and investigate Mr Hankin’s death without considering the inherent conflict of interest in so doing. The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. This gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths. ”
Source location
Keith James Hankin · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the serious incident and identify all associated learning and recommendations.

Verbatim wording from the response
“Learning from Mr Hankin’s death. NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
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
Follow up completion of serious-incident recommendations through enhanced contract quality meetings.

Verbatim wording from the response
“Following the Inquest Goring Hall Hospital have submitted the final version of the Serious Incident which has followed the Serious Incident Framework. NHS Sussex have reviewed the incident and have identified that all learning and recommendations have been identified. NHS Sussex through enhanced contract quality meetings will follow up to ensure that recommendations are complete. The next meeting is on 14th November 2025.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.

Verbatim wording from the response
“Management of Mr Hankin at Goring Hall Hospital. NHS Sussex ICB have served a contract performance notice to Goring Hall Hospital (Circle Health Group) in respect of services delivered at Goring Hall Hospital, following concerns about the governance and response to a serious patient safety incident. The CPN cited breaches of the NHS Standard Contract, including failure to meet clinical standards, failure to act meaningfully on serious incident learning, and lack of transparent quality assurance.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
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 ICB is not responsible for investigating serious incidents involving individual patient care.

Verbatim wording from the response
“Learning from Mr Hankin’s death. NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.

Verbatim wording from the response
“Learning from Mr Hankin’s death. NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.”

Source location
Response from NHS Sussex
Page 3 · response
Published 19 September 2025
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 provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.

Verbatim wording from the response
“Regarding reviewing the causes of Mr Hankin’s death and the risk of a lack of transparency, Mr Hankin’s case was reviewed by the provider under the National Serious Incident (SI) framework as it occurred in 2023. NHS Sussex have reviewed the SI as per ICB scrutiny process and the SI has been closed. This provider review is the same process that any provider would undertake following the SI Framework. The ICB would consider an independent review if the quality of the provider report was an issue or did not elicit appropriate learning. The provider SI identified appropriate learning and subsequent actions.”

Source location
Response from Department for Health and Social Care
Page 3 · response
Published 19 September 2025
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 Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.

Verbatim wording from the response
“We will leave it to the ICB to comment on any actions it took following Mr Hankin's death. Insofar as your concerns regarding SMC's review of his death are concerned, it is incorrect to say that ████████ allegedly investigated Mr Hankin's death. The circumstances of his death were reviewed at a clinical governance meeting on 1 November 2023 at which I was present along with ████████ who is a consultant in renal medicine at University Hospitals Sussex NHS Foundation Trust, ████████ (Director), ████████ (Operations Managers). We discussed the events leading up to Mr Hankin's death and the fact that Goring Hall Hospital was conducting its own investigation into Mr Hankin's care. We wrote to Goring Hall Hospital offering to input into their investigation, as is usual when treatment spans multiple providers.”

Source location
Response from Sussex Medical Chambers
Page 5 · response
Published 19 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.

Verbatim wording from the response
“We are unable to comment on the aspects of this concern that relate to the Integrated Care Board (ICB) as it falls outside the scope of our regulatory responsibilities. The Integrated Care Board (ICB), as a named respondent in this case, would be best placed to address this point and provide further clarification.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 19 September 2025
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 Integrated Care Board is best placed to address concerns about its oversight, governance and performance.

Verbatim wording from the response
“While the Care Quality Commission (CQC) has statutory powers to regulate providers of health and social care services, we do not hold regulatory authority over Integrated Care Boards (ICBs). Responsibility for the oversight, governance, and performance of ICBs lies with NHS England.”

Source location
Response from Care Quality Commission
Page 1 · response
Published 19 September 2025
Open published response
17 Sep2025
Swansea and Neath Port Talbot
Concerns raised1
1. Lack of understanding of evidence requiring preservation during domestic explosion investigations
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 3
1. Action
  Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.
  Stated by South Wales PoliceStated planned
2. Action
  Prepare national training material on work-related aspects of investigations, including advice for first responders.
  Stated by Health and Safety ExecutiveStated in progress
3. Action
  Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.
  Stated by Health and Safety ExecutiveStated in progress
Respondent positions 2
1. Position
  The National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.
  Stated by South Wales PoliceRedirects responsibility
1. Position
  The existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.
  Stated by Health and Safety ExecutiveExisting arrangements considered sufficient
AI-generated summary

Brian Lyn Davies · 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

Brian Lyn Davies was pronounced dead at his home on 13 March 2023 after sustaining chest and neck injuries in an explosion. The cause of the explosion could not be determined because material evidence was not preserved during the search and rescue and clean-up operations, and concerns were raised about the lack of guidance or a protocol between the Police and the HSE on preserving evidence from domestic explosions.

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 understanding of evidence requiring preservation during domestic explosion investigations
Wider context from the report
“During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation. The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation. It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events. I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence. 1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; 2. There was no order given to secure such evidence; 3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation ”
Source location
Brian Lyn Davies · 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
Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.

Verbatim wording from the response
“In this respect, South Wales Police will take steps to raise your concerns with the National Liaison Committee in order that due regard may be had to such a possibility in the future, so that any amendments which are considered appropriate, may be made to the Protocol.”

Source location
Response from South Wales Police
Page 4 · response
Published 19 December 2025
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
Prepare national training material on work-related aspects of investigations, including advice for first responders.

Verbatim wording from the response
“• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;”

Source location
Response from HSE
Page 3 · response
Published 19 December 2025
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 proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.

Verbatim wording from the response
“• Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas Incidents’. This would be for the NLC to agree and update the guide.”

Source location
Response from HSE
Page 3 · response
Published 19 December 2025
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 National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.

Verbatim wording from the response
“As would be expected, the Protocols contains provisions and guidance which provide full or partial answers to the issues you have raised. However, it remains important that the Protocols are reviewed and refreshed as appropriate. In this regard, it is significant that Detective Superintendent ████████ ████████ from South Wales Police attended the National Work Related Death Liaison Committee on 17 November 2025 which is the national multi agency meeting that oversees the Protocol and linked matters. At that meeting the Protocols, were discussed as it was universally agreed that these documents need to be updated. The motion to give effect to the same was carried, and the National Liaison Committee has committed to undertaking a review and update as appropriate.”

Source location
Response from South Wales Police
Page 3 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.

Verbatim wording from the response
“In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work Related Death Protocol (WRDP) addresses your points. I have responded to each of those points individually with excerpts from the protocol below.”

Source location
Response from HSE
Page 2 · response
Published 19 December 2025
Open published response
20 Aug2025
Manchester North
Concerns raised1
1. Ineffective investigation of deaths of detained patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review governance and decision-making around selecting and approving the learning review after the death.
  Stated by Pennine Care NHS Foundation TrustStated in progress
2. Action
  Consider and decide whether to change the process for reassessing learning reviews when additional information becomes available.
  Stated by Pennine Care NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The Trust disputes that a further investigation was required because no evidence then linked the death to problems in its care.
  Stated by Pennine Care NHS Foundation TrustDisputes the concern
AI-generated summary

Masood Hamid · 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

Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Ineffective investigation of deaths of detained patients
Wider context from the report
“2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983. As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent future deaths. ”
Source location
Masood Hamid · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review governance and decision-making around selecting and approving the learning review after the death.

Verbatim wording from the response
“At the time of Mr Hamid’s death, and when the SWARM Huddle was completed and progressed through our approval processes, some of the information that became apparent in inquest disclosure and subsequent evidence heard during the hearing was not known. As a consequence, the Executive Director of Nursing, Quality and AHP’s has commissioned a review of the governance and decision making around which type learning review was commissioned and undertaken following Mr Hamid’s sad death. This is being undertaken by the Head of Quality in our Tameside and Glossop Care Hub. This is to ensure this is considered independently of the Care Hub and Network in which the incident took place. As”

Source location
Response Pennine Care NHS Foundation Trust
Page 3 · response
Published 1 September 2025
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
Consider and decide whether to change the process for reassessing learning reviews when additional information becomes available.

Verbatim wording from the response
“It is possible that consideration of a change in process in how we assess if learning reviews are still effective in identifying learning when more information is made available, could be implemented. A decision around this will be made once we have an outcome from the review, which is expected by the end of November 2025. I would be happy to share the outcome of this review and any associated recommendations and actions that are identified once these are available.”

Source location
Response Pennine Care NHS Foundation Trust
Page 4 · response
Published 1 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust disputes that a further investigation was required because no evidence then linked the death to problems in its care.

Verbatim wording from the response
“Since you identified the above concern, further analysis and reflection was undertaken in the Trust’s Central Safety Summit. This was focused on the decision to undertake a SWARM Huddle, of its conclusion and closure, opposed to the commissioning of a further learning review, such as a Patient Safety Incident Investigation (PSII). As part of these discussions the Trust’s PSIRF Policy was consulted which indicates that a PSII should be undertaken for ‘Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care.’ At the time of Mr Hamid’s death, there was nothing to show following the completion of the learning review that Mr Hamid’s death was linked to any problems in relation to the care provided to Mr Hamid from the Trust.”

Source location
Response Pennine Care NHS Foundation Trust
Page 3 · response
Published 1 September 2025
Open published response
4 Aug2025
South Yorkshire (Eastern)
Concerns raised1
1. Failure to undertake a formal investigation of incidents
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 1
1. Action
  Investigate the incident through the broader thematic analysis and draft the thematic review and associated actions for Executive Team presentation.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progress
AI-generated summary

John Bell · 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

John Bell died at St John's Hospice Doncaster on 10 February 2025 after right upper lobe pneumonia contributed to by an infected spinal surgery wound, ischaemic heart disease and localised left renal carcinoma. The report raises concerns that critical renal tumour information was not available to or considered by the spinal surgeons before surgery, and that the incident was not formally investigated or subject to organisational learning for about eight months.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake a formal investigation of incidents
Wider context from the report
“2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the inquest no Datix report had been submitted. The witnesses accepted at inquest that a Datix would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred. ”
Source location
John Bell · 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 the incident through the broader thematic analysis and draft the thematic review and associated actions for Executive Team presentation.

Verbatim wording from the response
“I can confirm that a DATIX incident form was completed on 30 July 2025, and the investigation remains ongoing as part of a broader thematic analysis. A comprehensive thematic review and associated actions are currently being drafted for presentation to the Executive Team.”

Source location
Response from Doncaster and Bassetlaw Teaching Hospitals
Page 2 · response
Published 6 August 2025
Open published response
18 Jun2025
Manchester South
Concerns raised1
1. Failure to undertake serious incident investigations for learning
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.
Respondent positions 1
1. Position
  A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustNo action considered necessary
AI-generated summary

Valerie Hampson · 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

Valerie Hampson died at Willow Wood Hospice on 29 December 2024 as a consequence of Non-Hodgkin’s Lymphoma. The report raises concerns about the progression of a left knee wound while she was under District Nurse care, the absence of a serious incident investigation, and apparent failure to provide recommended fracture-clinic follow-up.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake serious incident investigations for learning
Wider context from the report
“I am concerned that the Trust has not undertaken any serious incident investigation with a view to identifying if any learning could usefully be identified in the light of the progression of Mrs Hampson’s left leg wound whilst under the care of the District Nurses. ”
Source location
Valerie Hampson · 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
A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.

Verbatim wording from the response
“Since the inquest we have revisit the care and treatment provided to Mrs Hampson. At the point the wound was noted to be deteriorating, Mrs Hampson was referred promptly back to the Emergency Department. The circumstances surrounding how the wound occurred and how it came to deteriorate did not fit the criteria for investigation in that:”

Source location
Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 3 July 2025
Open published response
7 Jun2025
North East Kent
Concerns raised1
1. Failure to conduct internal investigations for learning
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
  Provide additional support to the Medical Examiner team to identify cases for further investigation.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
2. Action
  Continue reviewing learning from incidents, complaints, claims and inquests to improve governance and patient safety.
  Stated by East Kent Hospitals University NHS Foundation TrustStated in progress
3. Action
  Undertake a full multidisciplinary case-note review of care and treatment preceding the final admission to identify earlier holistic recognition of decline.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
1. Action
  Include unexpected deaths routinely in clinical meeting discussions.
  Stated by Manor ClinicStated completed
AI-generated summary

Mrs Ann Caldicott · 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

Mrs Ann Caldicott had a long-standing history of weight loss, anaemia, declining renal function and frailty, and died in hospital on 21 February 2024 after a urinary catheter insertion caused a bladder perforation. The report identifies concerns that her malnutrition and declining frailty were not adequately investigated or treated, leaving her too physiologically frail for potentially lifesaving treatment. It also raises concerns that relevant internal investigations and reviews did not take place.

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 for learning
Wider context from the report
“2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary. 3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death. 4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place. 5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status. 6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation. ”
Source location
Mrs Ann Caldicott · 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
Provide additional support to the Medical Examiner team to identify cases for further investigation.

Verbatim wording from the response
“We have highlighted this case to the Lead Medical Examiner as the first point at which it was felt a Structured Judgement Review could have taken place. If this had happened then it would have triggered many other actions and the Trust could have learned from this case earlier than it has now. Individual feedback has been provided and additional support will be provided to the Medical Examiner team to allow them to better identify cases for further investigation.”

Source location
Response from East Kent Hospitals University
Page 3 · response
Published 15 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue reviewing learning from incidents, complaints, claims and inquests to improve governance and patient safety.

Verbatim wording from the response
“Regrettably, the clinician who gave evidence at the Inquest did not raise a Datix and therefore, once again, the opportunity to investigate and learn was lost. We apologise that this wasn’t completed in a timely manner but the clinicians have been received feedback and they have reflected on the importance of raising incidents for learning and improvement. The Trust realises this is not reassuring but we believe this to be an isolated incident. However, as part of our commitment to improving governance and patient safety, the Trust will continue to review learning from incidents, complaints, claims and inquests.”

Source location
Response from East Kent Hospitals University
Page 3 · response
Published 15 July 2025
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 full multidisciplinary case-note review of care and treatment preceding the final admission to identify earlier holistic recognition of decline.

Verbatim wording from the response
“A multi professional review of the 12 months care and treatment preceding her admission late 2023 will take place. This is described further later in this letter.”

Source location
Response from East Kent Hospitals University
Page 2 · response
Published 15 July 2025
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
Include unexpected deaths routinely in clinical meeting discussions.

Verbatim wording from the response
“5. Significant Event and Death Review”

Source location
Response from Manor Clinic
Page 2 · response
Published 15 July 2025
Open published response
21 May2025
North West Wales
Concerns raised1
1. Failure to conduct sufficiently thorough neonatal investigations
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 5
1. Action
  Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Implement a programme for investigating officers.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Direct that investigations across women’s and neonatal services use a single investigation officer.
  Stated by Betsi Cadwaladr University LHBStated completed
1. Action
  Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Appoint a quality governance officer to neonatal services to provide specialist investigation and review capacity.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Etta-Lili Stockwell-Parry · 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

Etta-Lili Stockwell-Parry was born in poor condition on 3 July 2023 and died four days later after transfer for specialist neonatal care. The report identified missed opportunities to recognise static growth and fetal distress, inadequate monitoring and incomplete records during labour, and concerns that the neonatal investigation and sharing of learning were insufficiently thorough and contextualised.

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 sufficiently thorough neonatal investigations
Wider context from the report
“a. The neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta’s resuscitation, nor did they meet with them to understand what had occurred. The investigation was based on records alone. The records themselves, identified as part of the investigation, were often incomplete or included retrospective entries. Despite this, the investigator nor the panel involved considered speaking to or obtaining statements from crucial individuals. ”
Source location
Etta-Lili Stockwell-Parry · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.

Verbatim wording from the response
“In relation to investigations, as you know this is an area of improvement I have prioritised. Last year, a new Integrated Concerns Policy was approved in June 2024 by the Board”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 22 May 2025
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 a programme for investigating officers.

Verbatim wording from the response
“and implemented in September 2024. This new policy provides a single, integrated approach to incident, complaint and mortality reviews and investigations. The patient safety, complaint and mortality review teams are now working together as a more integrated hub to coordinate investigations, supported by a daily hub review meeting and a weekly clinical executive led meeting. A new programme for investigating officers has been implemented. The new policy also requires that all those involved in an incident are engaged in the process including receiving the sharing of information.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 22 May 2025
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
Direct that investigations across women’s and neonatal services use a single investigation officer.

Verbatim wording from the response
“Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 22 May 2025
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
Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.

Verbatim wording from the response
“Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 22 May 2025
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 a quality governance officer to neonatal services to provide specialist investigation and review capacity.

Verbatim wording from the response
“separate reviews were undertaken and then brought together). This will directly address quality and consistency, in line with how all other services operate. In addition, a directive has been issued that investigations across women’s services will use the framework and templates within the Integrated Concerns Policy (as opposed to the PMRT tool which was used for Etta’s case). The national tool will continue to be used however investigations will follow the established Health Board format. We have also appointed a new quality governance officer into neonatal services which will ensure access to local specialist skills and capacity for investigations and reviews.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 22 May 2025
Open published response
20 May2025
Birmingham and Solihull
Concerns raised1
1. Failure to investigate deaths and learn from work-related events and welfare support
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 2
1. Action
  Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.
  Stated by West Midlands Fire ServiceStated planned
2. Action
  Share learning from the case to improve support for senior officers nationally.
  Stated by West Midlands Fire ServiceStated planned
AI-generated summary

Mr Brown · Prevention of Future Deaths report

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

Report summary

Mr Brown was found hanging at his home on 24 January 2024 and was confirmed deceased by police. The report identified concerns about the lack of post-death investigation and the absence of adequate welfare support and welfare-recording mechanisms for senior staff experiencing significant stress or disciplinary investigations.

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 deaths and learn from work-related events and welfare support
Wider context from the report
“1. WMFS did not undertake any investigation after Mr Brown’s death and have no policy requiring them to do so. Any opportunity to learn from a death such as a suicide related to work events including what welfare support was provided has not been addressed. This creates a risk of future deaths and action should be taken. ”
Source location
Mr Brown · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.

Verbatim wording from the response
“However, we acknowledge that the terms of reference of a review of this nature could be enhanced to ensure that learning is maximised and built into our policies and the outcomes from it better analysed to ensure that appropriate actions are built into our structures.”

Source location
Response from West Midlands Fire Service
Page 2 · response
Published 22 May 2025
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 learning from the case to improve support for senior officers nationally.

Verbatim wording from the response
“We are committed to sharing the learning from this case to help improve support nationally.”

Source location
Response from West Midlands Fire Service
Page 3 · response
Published 22 May 2025
Open published response
12 May2025
East London
Concerns raised1
1. Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.
  Stated by Barts Health NHS TrustStated planned
Respondent positions 2
1. Position
  Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Kenneth Foster · Prevention of Future Deaths report

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

Report summary

Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Wider context from the report
“A. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate. ”
Source location
Kenneth Foster · 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
Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.

Verbatim wording from the response
“Since December 2024, at Whipps Cross Hospital, each new inquest opened is reported via the incident reporting system (Datix). The cases are presented at the Patient Safety Incident Response Meeting (PSIRM) and where a Mortality and Morbidity Meeting (M&M) has not yet been held, arrangements are made to expedite this process to inform decision making around the type of learning response required in accordance with the Patient Safety Incident Response Plan.”

Source location
2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025
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
Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.

Verbatim wording from the response
“As part of the learning from this PFD, the Whipps Cross Hospital Senior Leadership Team will ensure that families are contacted as part of the Patient Safety Incident Review Meeting (PSIRM) process to ensure that a more robust review is undertaken. Taking account of family concerns should be a key aspect to inform decision making around the level of investigation required. This action will also ensure reviews include the views of the patient’s family, in line with Patient Safety Incident Response Framework (PSIRF) compassionate engagement principles.”

Source location
2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025
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 specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.

Verbatim wording from the response
“In order to gain additional assurance, the Trust has commissioned a review to be undertaken by a specialist within the North London Integrated Care Board and supported by NHSE to review”

Source location
2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025
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
Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.

Verbatim wording from the response
“While PSIRF represents a significant improvement to the way that the NHS responds to patient safety incidents, PSIRF does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient.”

Source location
2025-0231-Response from The Department of Health and Social Care
Page 1 · response
Published 21 May 2025
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
Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.

Verbatim wording from the response
“As such, under PSIRF, not all deaths will be investigated. This will include some which go to inquest. Decision-making regarding patient safety incident response should be documented by Trusts as part of a robust governance process. Where a specific learning response is not undertaken in relation to an incident discussed at inquest, the organisation should be able to explain why this was the case.”

Source location
2025-0231-Response from The Department of Health and Social Care
Page 1 · response
Published 21 May 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to identify and preserve the accounts of staff directly involved in errors

Failure of investigations to identify and question relevant medical team members

Delays in commencing investigations and after-action reviews of recognised errors

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

Concerns raised1

Lack of independent review of deaths for learning and practice change

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6

Concerns raised1

Lack of understanding of evidence requiring preservation during domestic explosion investigations

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Ineffective investigation of deaths of detained patients

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

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

Concerns raised1

Failure to undertake a formal 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.1

Concerns raised1

Failure to undertake serious incident investigations for learning

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 1

Actions described in response 3

Respondent positions 6

Actions described in response 3

Respondent positions 2

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 1