Recurring concern

Inadequate safety incident investigations

First to latest report 13 Dec 2008 — 25 Jun 2026

Reports that mention this concern: 244
Times this concern has been raised: 316
Stated actions linked to this concern: 447

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 244 reports

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

7 Feb2025
Nottinghamshire
Concerns raised1
1. Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

HM Prison and Probation Service
Sodexo
Stated actions 1
1. HM Prison and Probation Service
  Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Respondent positions 2
1. HM Prison and Probation Service
  Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.
  Existing arrangements considered sufficient
1. Sodexo
  Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
  Unable to act
AI-generated summary

Anthony Binfield and 2 others · 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

Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.

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 an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report
“HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place. ”
Source location
Anthony Binfield and 2 others · Prevention of Future Deaths report
Page 5 · 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
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.

Verbatim wording from the response
“More generally HMPPS is committed to learning from all deaths and to taking action to address any issues that are identified as a result. The Follow-up to Deaths in Custody policy framework describes the early learning review process for all apparently non-natural deaths, through which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the National Safety Group. It also explains our commitment to supporting the various independent investigations processes that follow a death and particularly to meeting our duty of candour, including by disclosing all relevant documents.”

Source location
Response from HMPPS
Page 7 · response
Published 13 February 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
Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.

Verbatim wording from the response
“I am sorry that there were delays in the disclosure of material during these inquests. We have reviewed the handling of the inquests with Government Legal Department (GLD) and we believe that this was the result of the unusual circumstances of this case, which had a broad scope that reached into areas not commonly subject to such investigation. The Follow-up to Deaths in Custody policy framework sets out very clearly the requirement to retain documents relevant to the death and specifically notes that there may be a considerable delay between the death and the inquest, and that the coroner may ask for documentation not requested by either the police or the PPO, pointing out that it is therefore crucial that prisons retain all documentation available. In the vast majority of cases prisons are complying with this guidance and it is proving sufficient to meet the needs of coroners.”

Source location
Response from HMPPS
Page 8 · response
Published 13 February 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
Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.

Verbatim wording from the response
“Whilst Sodexo always considers early admissions and agreed facts, the unique circumstances of these cases, with the number of overlapping organisations involved and individual officers with separate IP status, as well as ongoing and late disclosure of relevant material by the Ministry of Justice, meant that admissions by Sodexo, without trespassing on factual evidence due to be heard at the inquest involving other IPs, was more difficult and complex than would usually be the case. There are three further inquests involving Sodexo concerning deaths at HMP Lowdham Grange, and Sodexo will give careful consideration to admissions and agreement of facts in relation to each.”

Source location
Response from Sodexo
Page 3 · response
Published 13 February 2025
Open published response
30 Jan2025
Inner South London
Concerns raised3
1. Delegation of investigations without terms of reference
2. Investigation conclusions based on assumptions
3. Failure to explore all relevant investigation scenarios
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Mills Family Limited
Stated actions 1
1. Mills Family Limited
  Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
AI-generated summary

James Collier SIDDONS · 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

James Collier Siddons, who had very severe frailty and multiple co-morbidities, was admitted to hospital after sustaining a fractured left humerus at a nursing home. He subsequently developed aspiration pneumonia and pyelonephritis and died suddenly from sepsis on 31 January 2022. Concerns were raised that the investigation into his fracture was flawed, that the organisation lacked detailed investigation guidance and routine training, and that relevant issues were not communicated promptly by the local authority.

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
Delegation of investigations without terms of reference
Wider context from the report
“1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt a. It failed to explore all the scenarios that might have accounted for fracture. b. It was in part delegated to a deputy manager without terms of reference c. Mills Family senior management was not involved d. The investigation’s conclusions were based on assumptions ”
Source location
James Collier SIDDONS · 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
Investigation conclusions based on assumptions
Wider context from the report
“1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt a. It failed to explore all the scenarios that might have accounted for fracture. b. It was in part delegated to a deputy manager without terms of reference c. Mills Family senior management was not involved d. The investigation’s conclusions were based on assumptions ”
Source location
James Collier SIDDONS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to explore all relevant investigation scenarios
Wider context from the report
“1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt a. It failed to explore all the scenarios that might have accounted for fracture. b. It was in part delegated to a deputy manager without terms of reference c. Mills Family senior management was not involved d. The investigation’s conclusions were based on assumptions ”
Source location
James Collier SIDDONS · 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
Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.

Verbatim wording from the response
“1. To re-emphasise to all managers and deputy managers that all serious incidents should be notified to the senior management team in line with company policies. Further, re-emphasise that input from the Director of Care, Mandy Finn, should be sought before any investigation report or serious incident report is finalised and circulated.”

Source location
Response from Mills Family Ltd
Page 1 · response
Published 30 January 2025
Open published response
9 Jan2025
Oxfordshire
Concerns raised2
1. Use of narrowly scoped and time-pressured structured reviews of incidents
2. Use of incident reviewers with potential conflicts of interest
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Oxford University Hospitals NHS Foundation Trust
Stated actions 2
1. Oxford University Hospitals NHS Foundation Trust
  Modify the Structured Judgement Review template to prompt reviewers to identify concerns about the review’s scope or focus.
2. Oxford University Hospitals NHS Foundation Trust
  Require reviewers to confirm before completing a Structured Judgement Review whether they have a conflict of interest.
Respondent positions 1
1. Oxford University Hospitals NHS Foundation Trust
  The existing Structured Judgement Review process requires whole-record review, allows sufficient time, and enables concerns about care quality to be escalated.
  Existing arrangements considered sufficient
AI-generated summary

David Vincent Tighe · 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

David Vincent Tighe, a 59-year-old man receiving chemotherapy for cancer, was admitted to hospital with chemotherapy-induced enterocolitis. During his treatment, bile aspiration occurred after insufficient monitoring and displacement of a Ryles tube, contributing to bronchopneumonia and sepsis, from which he died. The principal concerns were the absence of a specific Ryles tube policy and the use of a narrowly focused structured review that could miss care or procedural problems.

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
Use of narrowly scoped and time-pressured structured reviews of incidents
Wider context from the report
“Absence of a Ryles tube policy: 1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice. Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death. Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed. Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring. At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023. It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required. The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure. Use of a narrowly focussed structured review by a treating clinician: 2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment. The Structured Review consequently overlooked considering several issues including: (i) missing bile drainage entries. (ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021). (iii) the absence of Repeat Position Checks for the Ryles tube. (iv) the absence of any written record of family concerns that were raised with a ward sister. Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review. That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance. Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied. ”
Source location
David Vincent Tighe · 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
Use of incident reviewers with potential conflicts of interest
Wider context from the report
“Absence of a Ryles tube policy: 1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice. Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death. Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed. Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring. At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023. It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required. The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure. Use of a narrowly focussed structured review by a treating clinician: 2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment. The Structured Review consequently overlooked considering several issues including: (i) missing bile drainage entries. (ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021). (iii) the absence of Repeat Position Checks for the Ryles tube. (iv) the absence of any written record of family concerns that were raised with a ward sister. Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review. That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance. Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied. ”
Source location
David Vincent Tighe · 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
Modify the Structured Judgement Review template to prompt reviewers to identify concerns about the review’s scope or focus.

Verbatim wording from the response
“Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.”

Source location
Response from Oxfordshire University Hospitals NHS Foundation Trust
Page 2 · response
Published 27 March 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
Require reviewers to confirm before completing a Structured Judgement Review whether they have a conflict of interest.

Verbatim wording from the response
“Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.”

Source location
Response from Oxfordshire University Hospitals NHS Foundation Trust
Page 2 · response
Published 27 March 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 Structured Judgement Review process requires whole-record review, allows sufficient time, and enables concerns about care quality to be escalated.

Verbatim wording from the response
“The Trust has a robust process for training clinicians in performing Structured Judgement Reviews (SJRs). The training highlights the need to review the whole case record including the nursing records. It directs the reviewer to contact any individual or team if there are concerns about the quality of care provided. There is no limit put on the length of time to undertake an SJR. Over 230 clinicians within OUH have been trained to date.”

Source location
Response from Oxfordshire University Hospitals NHS Foundation Trust
Page 2 · response
Published 27 March 2025
Open published response
7 Jan2025
Buckinghamshire
Concerns raised1
1. Failure to conduct adequate investigations of adverse incidents
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Chiltern Care Services
Stated actions 1
1. Chiltern Care Services
  Instruct an external person or organisation to investigate each future death.
AI-generated summary

Sheila Ann Nicholls · 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

Sheila Ann Nicholls died after choking on food during respite care at Mandeville Grange Nursing Home on 19 November 2023. Her family had warned the nursing home about her swallowing difficulties, but important information was not recorded or shared, and she was given food that was unsuitable or insufficiently prepared. The report raised concerns about policy management, emergency response training, and the investigation and learning from adverse incidents.

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 adequate investigations of adverse incidents
Wider context from the report
“3. Evidence was given of two internal investigations undertaken by Mandeville Grange management following Sheila’s death, both of which failed to adequately consider significant matters. The investigations were performed by staff untrained in investigating adverse incidents. The inability to adequately investigate such matters creates a risk of death to future residents given deficiencies in care may not be identified or remedied in a timely manner. At the time of the inquest, the nursing home’s expressed intention was to instruct an external person or organisation to investigate future unexpected or unnatural deaths. ”
Source location
Sheila Ann Nicholls · 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
Instruct an external person or organisation to investigate each future death.

Verbatim wording from the response
“We remain committed to instructing an external person or organisation to investigate any future deaths.”

Source location
Response from Mandeville Grange Nursing Home
Page 3 · response
Published 13 January 2025
Open published response
2 Jan2025
Cheshire
Concerns raised1
1. Failure to conduct internal investigations of care outside safeguarding processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Springcare
Springcare (Macclesfield) Ltd t/a Henning Hall
Respondent positions 1
1. Springcare and Springcare (Macclesfield) Ltd t/a Henning Hall
  Existing investigation and learning arrangements are appropriate; no further changes are required beyond measures already discussed at the inquest.
  Existing arrangements considered sufficient
AI-generated summary

Victor William Knowles · 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

Victor William Knowles was admitted to a nursing home for short-term care planning while at high risk of dehydration and malnutrition. He lost 5kg, had very low fluid intake, and later required hospital treatment for severe dehydration and malnutrition, acute kidney injury, hypernatremia and osmotic demyelination syndrome before dying on 20 January 2024. Concerns included inaccurate or incomplete information being shared with healthcare professionals, failures to obtain timely medical treatment, and limited investigation, reflection and learning from his care and death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to conduct internal investigations of care outside safeguarding processes
Wider context from the report
“1. The evidence highlighted that the only internal investigation that took place in respect of the care provided to Victor was in the context of safeguarding and as a consequence of a request from the Local Authority, under section 42 of the Care Act 2014, following the submission of safeguarding referrals by the Hospital after Victor’s death. ”
Source location
Victor William Knowles · 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
Existing investigation and learning arrangements are appropriate; no further changes are required beyond measures already discussed at the inquest.

Verbatim wording from the response
“The Home has at all times had in place a comprehensive policy for undertaking internal investigations including guidance on when these are required. As you will appreciate, given the setting in which the Home operates, it would not be reasonably practicable nor proportionate to commence an investigation following all deaths or admissions to hospital. Rather, this requires the review of all incidents whereby a sudden death occurs or any unexpected hospital admission. Furthermore, a monthly review of deaths and hospital admissions considers any themes or trends. This is consistent with the protocols observed by care homes throughout the industry. We are also obliged to notify the Care Quality Commission of deaths in our home without delay under our provider and manager registration.”

Source location
Response from Springcare Care Homes Ltd
Page 1 · response
Published 9 January 2025
Open published response
23 Dec2024
East Riding and Hull
Concerns raised1
1. Lack of internal investigation of serious incidents
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS Humber Health Partnership
Stated actions 1
1. NHS Humber Health Partnership
  Complete Structured Judgement Reviews for all patients with identified learning disabilities who die while receiving Trust care.
Respondent positions 2
1. NHS Humber Health Partnership
  The Trust did not declare a serious incident because harm was not deemed to have been caused by the Trust.
  Disputes the concern
1. NHS Humber Health Partnership
  The Humber Steering Group manages the LeDeR action plan across the ICB, while Trust-related actions are monitored through the LeDeR Panel Review Group.
  Redirects responsibility
AI-generated summary

David Christopher Peter Lodge · 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

David Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious incident investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of internal investigation of serious incidents
Wider context from the report
“(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team. ”
Source location
David Christopher Peter Lodge · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete Structured Judgement Reviews for all patients with identified learning disabilities who die while receiving Trust care.

Verbatim wording from the response
“55. However, since Mr Lodge’s death, Trust process and procedure has developed and going forward a Structured Judgement Review (SJR) is completed for all patient’s with identified learning disabilities and who sadly pass away while receiving care and treatment at the Trust. The SJR will be completed by the Vulnerabilities and Enhanced Care. The SJR will be completed despite the outcome of the initial clinical review of the care and treatment provided and despite the outcome of the decision from LeDeR in terms of their investigation.”

Source location
Response from Humber Health
Page 14 · response
Published 24 January 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 did not declare a serious incident because harm was not deemed to have been caused by the Trust.

Verbatim wording from the response
“53. Information of Davids death was provided by the emergency department to the Mental Capacity Act lead. No concerns were raised regarding omissions in care or treatment during the hours spent at Hull University Teaching Hospitals. A safeguarding concern was submitted to the relevant Local Authority for investigation due to the pathway of admission and prior knowledge of community safeguarding issues. Mr Lodge’s death was also reported to LeDeR who confirmed that a review of care would be completed at the conclusion of the inquest.”

Source location
Response from Humber Health
Page 14 · response
Published 24 January 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 Humber Steering Group manages the LeDeR action plan across the ICB, while Trust-related actions are monitored through the LeDeR Panel Review Group.

Verbatim wording from the response
“58. Programme relevant to the Services. This includes the Learning Disabilities Mortality Review programme (LeDeR) of which NHS Humber Health Partnership is a member of the Humber Steering Group. Mr Lodge’s case was referred to LeDeR prior to the inquest and action was to be considered following the conclusion of the inquest. The Trust are aware that the LeDeR Panel Review Group are carrying out of full review of the care and treatment Mr Lodge received. The Panel Review Group meet every two weeks and the action plan ensuing from the review, which relates to the Trust will be monitored at the Panel Review meetings. The action plan across the ICB would be managed by the Humber Steering Group.”

Source location
Response from Humber Health
Page 15 · response
Published 24 January 2025
Open published response
20 Dec2024
Worcestershire
Concerns raised1
1. Failure of internal investigations to identify deficiencies in handover documents
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Care UK
Stated actions 2
1. Care UK
  Implement the revised Safety Incident Response Framework for serious-incident investigations.
2. Care UK
  Ensure future serious incidents are investigated by an independent Home Manager under the Safety Incident Response Framework.
AI-generated summary

Edith Theresa PYE · 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

Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal 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 internal investigations to identify deficiencies in handover documents
Wider context from the report
“5) The Deputy Manager who had drafted this handover document, was also responsible for the care home’s own internal investigation into Mrs. Pye’s fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner’s Office until the final inquest hearing. ”
Source location
Edith Theresa PYE · 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 revised Safety Incident Response Framework for serious-incident investigations.

Verbatim wording from the response
“In September 2024 Care UK introduced a revised Safety Incident Response Framework (SIRF) policy based on the NHS Patient Safety Incident Response Framework that was also issued last year by the NHS. This policy places the responsibility to investigate serious incidents on Home Managers, so that incidents are investigated by an independent individual.”

Source location
2024-0706 - Response from Care UK Ltd
Page 4 · response
Published 27 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ensure future serious incidents are investigated by an independent Home Manager under the Safety Incident Response Framework.

Verbatim wording from the response
“The incident involving Mrs. Pye occurred prior to the roll-out of the new policy and the training provided to support the implementation of the policy. The Deputy Manager who investigated this incident no longer works for Care UK and any future investigation will be completed by an independent Home Manager as per the SIRF policy.”

Source location
2024-0706 - Response from Care UK Ltd
Page 4 · response
Published 27 December 2024
Open published response
13 Dec2024
Essex
Concerns raised1
1. Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Mid and South Essex NHS Foundation Trust
Stated actions 1
1. Mid and South Essex NHS Foundation Trust
  Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.
AI-generated summary

LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

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 obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage
Wider context from the report
“(12) No accounts were taken from Haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood products were prepared, dispensed and then administered where the timings and sharing of information were important to understand. ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.

Verbatim wording from the response
“We have now renewed and improved our processes regarding MNSI investigations. The revised processes ensures that all staff involved in the incident are shared the draft report to facilitate the opportunity to comment for factual accuracy and for these comments to be shared with MNSI.”

Source location
Response from Mid & South Essex NHS Trust
Page 12 · response
Published 18 December 2024
Open published response
10 Dec2024
West Yorkshire Eastern
Concerns raised1
1. Inadequate systems for timely review of patient safety incidents and learning from findings
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Meanwood Group Practice
Stated actions 2
1. Meanwood Group Practice
  Complete and discuss a full significant event analysis of the case.
2. Meanwood Group Practice
  Apply a lower threshold for completing significant event analyses, discussing them weekly and recording and acting on lessons.
AI-generated summary

Karen Lesley Day · 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

Karen Lesley Day sustained a leg laceration in 2021 and received care from her GP practice and district nursing team. She was later admitted to hospital extremely unwell, did not respond to active treatment, and died on 14 July 2022. Concerns were raised that the lower limb framework was not followed consistently, referrals and escalation were inadequate, and the practice lacked adequate systems for timely internal investigation of patient safety incidents.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate systems for timely review of patient safety incidents and learning from findings
Wider context from the report
“(2) During the inquest I received evidence that the practice had not carried out any internal investigation in relation to this death and the practice accepted it should have done. I am concerned that the practice does not have adequate systems in place to ensure that patient safety incidents are reviewed in a timely way to allow lessons to be drawn from the findings. ”
Source location
Karen Lesley Day · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete and discuss a full significant event analysis of the case.

Verbatim wording from the response
“The case had previously been discussed at a practice meeting on 25th July 2022 following the death of Ms Day. This is done for all patient deaths, and includes GPs, practice manager, practice pharmacist, and lead practice nurse. As with other case reviews it provided an opportunity to review and learn from the case.”

Source location
Response from Meanwood Group Practice
Page 1 · response
Published 11 December 2024
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
Apply a lower threshold for completing significant event analyses, discussing them weekly and recording and acting on lessons.

Verbatim wording from the response
“• The practice will have a lower threshold to complete a full significant event analysis. These will be discussed in the weekly practice clinical meeting and any lessons learnt recorded and acted on.”

Source location
Response from Meanwood Group Practice
Page 3 · response
Published 11 December 2024
Open published response
6 Dec2024
Birmingham and Solihull
Concerns raised1
1. Failure of investigations to address relevant clinical issues
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michael John THOMPSON · 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 John THOMPSON underwent hindquarter amputation for chondrosarcoma and later collapsed after vomiting; post-mortem examination found an internal hernia through a peritoneal defect, leading to aspiration. Concerns were raised that the peritoneal defect and repair were not recorded in the operation note, and that the Trust’s investigation did not address this issue or adequately support learning from the death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of investigations to address relevant clinical issues
Wider context from the report
“2. Under the PSIRF process a PSII investigation was undertaken however this only dealt with resuscitation efforts and did not address the peritoneal defect and its repair which was the root cause of Mr Thompson’s death. This raises a concern about the adequacy of investigations being undertaken by the Trust and their ability to learn from deaths. ”
Source location
Michael John THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material

Linked responses

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

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

Concerns raised3

Delegation of investigations without terms of reference

Investigation conclusions based on assumptions

Failure to explore all relevant investigation scenarios

Linked response

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

Concerns raised2

Use of narrowly scoped and time-pressured structured reviews of incidents

Use of incident reviewers with potential conflicts of interest

Linked response

Stated actions 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 conduct adequate investigations of adverse incidents

Linked response

Stated actions 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 conduct internal investigations of care outside safeguarding processes

Linked responses

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

Concerns raised1

Lack of internal investigation of serious incidents

Linked response

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

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

Concerns raised1

Failure of internal investigations to identify deficiencies in handover documents

Linked response

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

Stated actions 1

Respondent positions 2

Stated actions 1

Stated actions 2

Respondent positions 1

Stated actions 1

Respondent positions 1

Stated actions 1

Respondent positions 2

Stated actions 2