25 Jun 2024 John Howe · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure factual accuracy in Serious Incident Review reports View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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John Howe · Prevention of Future Deaths report
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Report summary
John Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure factual accuracy in Serious Incident Review reports
Wider context from the report “(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies , giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” Source location John Howe · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Correct inaccuracies in the Serious Incident Review and reshare the amended report with relevant safeguarding teams.
Verbatim wording from the response “I am extremely saddened by the events of the Mr John Howe’s death and, following your report, we have amended the inaccuracies in the report and reshared the Serious Incident Review (SIR) with Derbyshire Safeguarding Adults Board. I have also rehashed the amended SIR with Manchester Foundation Trust Safeguarding Team.” Source location Response from MCC
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PFD Monitor interpretation Share consultation agencies’ information for review and accuracy checking before finalising Serious Incident Reviews.
Verbatim wording from the response “We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report.” Source location Response from MCC
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Concerns raised 1
Failure of serious incident investigations to robustly and critically examine all relevant care issues View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Christopher Henrik LARSEN · Prevention of Future Deaths report
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Report summary
Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of serious incident investigations to robustly and critically examine all relevant care issues
Wider context from the report “4. The Serious Investigation and Reporting Process at LPT
I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.
The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan.
There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation .
Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff.
I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients , further, I have concerns about the ability of the Trust to embed changes and learning.
This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust.
” Source location Christopher Henrik LARSEN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.
Verbatim wording from the response “We take learning form serious incidents very seriously and have taken on board feedback provided relating to the processes within the Trust. All serious incident reports are reviewed by the Medical Director and Chief Nurse to ensure that they provide a critical analysis and investigation of the care provided to patients. We also recognise that the transition to the new National Patient Safety Incident Response Framework (PSIRF) has taken time to embed. Feedback from the new PSIRF process has been positive from families and clinicians. In order to make the process more robust a rapid improvement programme is underway to utilise quality improvement methodology to identify any improvements which can be made to the process.” Source location Response from Leicestershire Partnership NHS (2)
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13 Jun 2024 Graham FAULKNER · Prevention of Future Deaths report Cheshire
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Concerns raised 4
Investigation selection criteria failing to include paraplegia injuries View source Failure to conduct prompt investigations of serious workplace incidents View source Investigation selection criteria failing to include RIDDOR 4(2) incidents View source
Lack of discretionary investigation-selection criteria for incidents warranting investigation View source See 1 more concern
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Graham FAULKNER · Prevention of Future Deaths report
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Report summary
Graham Faulkner was exposed to caustic soda at work in October 2015, later developed paraplegia, and died in 2019 from sequelae of the injury. The principal concern was that the HSE did not promptly investigate the incident, resulting in evidence being unavailable or delayed and making it harder to establish the facts and learn from the death. The inquest conclusion also referred to failures in the administration and management of the Permit to Work process and a lack of challenge around PPE.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Investigation selection criteria failing to include paraplegia injuries
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia , given the life changing severity of such injuries .
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” Source location Graham FAULKNER · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct prompt investigations of serious workplace incidents
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate . Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” Source location Graham FAULKNER · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Investigation selection criteria failing to include RIDDOR 4(2) incidents
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” Source location Graham FAULKNER · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of discretionary investigation-selection criteria for incidents warranting investigation
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” Source location Graham FAULKNER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff to apply the Incident Selection Criteria pragmatically and obtain managerial advice when its application is uncertain.
Verbatim wording from the response “However, I can assure you that the Principal Inspectors who are reviewing such RIDDOR reports would not hesitate to consider paraplegia as being a severe injury just because it is not specifically listed. Our staff are trained to be pragmatic in the application of the ISC to ensure that we respond where appropriate to serious injury incidents and are not restricted solely by examples. HSE staff can seek advice from line managers should they be unsure of ISC application and regularly do so.” Source location Response from Health and Safety Executive
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move Incident Selection Criteria review and incident prioritisation from harm-outcome selection toward risk-based selection.
Verbatim wording from the response “HSE guidance is reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. Reviewing our ISC approach has been a recent area of work for HSE and we are moving away from selecting incidents by harm outcome and instead selecting by risk. So although I have passed your suggestion for ‘paraplegia’ to be specifically named in the ISC to HSE’s policy team for consideration at the time of the next ISC review, it is likely that we will focus more in future on risk rather than injury.” Source location Response from Health and Safety Executive
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider specifically naming paraplegia in the Incident Selection Criteria at the next review.
Verbatim wording from the response “HSE guidance is reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. Reviewing our ISC approach has been a recent area of work for HSE and we are moving away from selecting incidents by harm outcome and instead selecting by risk. So although I have passed your suggestion for ‘paraplegia’ to be specifically named in the ISC to HSE’s policy team for consideration at the time of the next ISC review, it is likely that we will focus more in future on risk rather than injury.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Omission of paraplegia from listed categories does not prevent staff from treating it as a severe injury and considering investigation.
Verbatim wording from the response “However, I can assure you that the Principal Inspectors who are reviewing such RIDDOR reports would not hesitate to consider paraplegia as being a severe injury just because it is not specifically listed. Our staff are trained to be pragmatic in the application of the ISC to ensure that we respond where appropriate to serious injury incidents and are not restricted solely by examples. HSE staff can seek advice from line managers should they be unsure of ISC application and regularly do so.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A meaningful investigation could not be conducted because too much time had passed and key evidence was unavailable.
Verbatim wording from the response “We also considered whether there was any realistic possibility of conducting an investigation at that time in 2019, however concluded that unfortunately too much time had passed meaning key evidence was unavailable to be able to conduct a meaningful investigation. We updated both the Police and Coroner’s Office of that decision at that time. We also updated Mr Faulkner’s next of kin and more recently met them jointly with the Police, ahead of the inquest, to further respond to their questions.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Incident Selection Criteria already permits investigation of any RIDDOR incident indicating a likely serious breach, including Regulation 4(2) notifications.
Verbatim wording from the response “There is more information about the ISC’s application within HSE Investigation Procedure which is also publically available at Investigation - Stage 2: Decide whether to investigate (hse.gov.uk). The ISC is focussed on RIDDOR reports under Regulation 4(1) to ensure highest injury type incidents are prioritised for investigation consideration. However, the ISC also includes an option at section 4 which allows for any type of RIDDOR to be considered for investigation should it indicate a likelihood serious breach of health and safety law. Thus our view is that the ISC already has the type of flexibility you are suggesting to help learn lessons from incidents where standards are far from where they should be, including linked to a Reg 4(2) notification.” Source location Response from Health and Safety Executive
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29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Poor-quality investigations failing to generate organisational learning View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report
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Report summary
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Source location Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a tabletop review of the investigation process and identify learning on investigation triggers, recording, scope, investigator capability, and quality assurance.
Verbatim wording from the response “As part of the reflections immediately post inquest, a tabletop review of the process followed in this case was requested by the Executive Director of Quality, Nursing and Healthcare Professionals, who had taken up his post in the weeks before the inquest. This review was led by a member of the Director team and identified learning.” Source location Response from Pennine Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate investigation-process recommendations into the Trust’s organisational change under the Patient Safety Incident Response Framework.
Verbatim wording from the response “These findings were received and accepted by our new Executive Director of Quality, Nursing and Health Professionals who is being supported by the Interim Head of Patient Safety and Clinical Effectiveness to dovetail these recommendations into our broader change in organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework” Source location Response from Pennine Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a training programme to enhance staff capability in reviewing and learning from patient-safety incidents.
Verbatim wording from the response “(PSIRF). As part of this, we are also commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents. This is intended to build on the existing offer available to staff, to create a robust system and pool of those able to undertake this responsibility effectively and efficiently.” Source location Response from Pennine Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a Central Safety Summit and associated governance processes for significant patient-safety investigations, with Trust Board and Quality Committee oversight.
Verbatim wording from the response “In order to facilitate the recommendations, the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes into our agreed structure which should support a more robust process for the most significant patient safety investigations. One of these is a Central Safety Summit, with an approved scope and purpose agreed at Trust Board level, with reporting into our Quality Committee to ensure continuous oversight at a Non-Executive Director level.” Source location Response from Pennine Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about health and wellbeing colleges are assigned to NHS England and Pennine Care NHS Foundation Trust, with the Trust responding directly.
Verbatim wording from the response “You have also raised concerns about health and wellbeing colleges and, in preparing this response, Departmental officials have made enquiries with NHS England and Pennine Care NHS Foundation Trust. I understand that the Trust is also in the process of responding to you directly.” Source location Response from DHSC
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13 May 2024 Elvon Paul Randolph Morton · Prevention of Future Deaths report East London
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Concerns raised 1
Inadequacy and siloing of incident reporting and mortality review processes View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Elvon Paul Randolph Morton · 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
Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequacy and siloing of incident reporting and mortality review processes
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. 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
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” Source location Elvon Paul Randolph Morton · Prevention of Future Deaths report
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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 Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
Verbatim wording from the response “Since November 2023, WXH have been in the process of implementing the Patient Safety Incident Response Framework. There is a very clear directive that unexpected deaths need to be reported via Datix and presented at Patient Safety Incident Review Meeting (PSIRM) so that an MDT decision can be made in terms of the correct learning response. In cases where care is thought to have led to the patient’s death a PSII will be undertaken (these investigations can take up to 6 months to complete). In other cases, an After-Action Review or SWARM should be undertaken, (where staff ‘swarm’ to review an incident) will be undertaken, these need to be completed within 12 weeks. In other cases, the PSIRM chair will request that the case be presented to M&M and the outcome reported back to PSIRM.” Source location Response from Barts Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Verbatim wording from the response “WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, learning responses and other key documentation are submitted in a timely manner (including statements). A proposal has been prepared to recruit a learning from deaths lead, their primary responsibility would be to drive improvement with stakeholder engagement including families, MEs, and coroners.” Source location Response from Barts Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.
Verbatim wording from the response “This patient’s death on 7 December 2022 was unexpected and was reported as an incident via the Datix reporting system but it was not presented for multidisciplinary team (MDT) discussion as a serious incident. The fail safe whereby a mortality and morbidity meeting triggers Serious Incident Review Assurance Panel (SIRMAP) discussion did not happen because although learning was identified the outcome was not felt to have been due to failures in care. Following a prompt from HM Coroner via the legal team, the case was presented to SIRMAP in July 2023 and the panel identified learning but did not find that the outcome could have been altered in this case.” Source location Response from Barts Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The primarily local concerns are for Barts Health NHS Foundation Trust to address.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.” Source location Response from DHSC
Open published response
Concerns raised 1
Investigation process failing to identify all learning from deaths View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ash BANNISTER · 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
Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Investigation process failing to identify all learning from deaths
Wider context from the report “It was accepted by United Children’s Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash’s death . If an investigation was undertaken by United Children’s Services after Ash’s death it:
(1) Was not documented;
(2) Failed to identify all of the learning uncovered at the inquest ;
(3) Failed to trigger any changes at United Children’s Services.
The investigation process in place at United Children’s Services is therefore not fit for purpose.
” Source location Ash BANNISTER · Prevention of Future Deaths report
Open source report
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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 an independent third party to conduct investigations under the Death and Serious Incidents Policy.
Verbatim wording from the response “We carried out our internal investigation in accordance with the organisation's Death and Serious Incidents Policy. This sets out the procedure that must be followed in the event of a death or serious incident concerning one of our young people. We initiated the investigation a few weeks after Ash died. A key part of that process is considering lessons that we can learn as an organisation. We regret that we did not document the investigation and our conclusions. The senior management team, who are responsible for such investigations, have been reminded that the full and proper procedure as set out in the Death and Serious Incidents Policy must be followed. We have also made a change to the Policy which now requires that an independent third-party conduct the investigation in line with the procedure set out in the Policy.” Source location Response from United Childrens Services
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24 Apr 2024 Olayemi Oluwarotimi Kodjo Kehinde · Prevention of Future Deaths report East London
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Concerns raised 1
Failure of the Trust to identify matters requiring a full governance investigation View source
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.
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AI-generated summary
Olayemi Oluwarotimi Kodjo Kehinde · 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
Olayemi Oluwarotimi Kodjo Kehinde, a 34-year-old man with a history of schizophrenia illness, walked into fast-moving traffic on 26 October 2023, was struck by a van, and later died from his injuries. Concerns related to staff supervision of escorted leave and the Trust’s ability to identify incidents requiring meaningful intervention or a full governance investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the Trust to identify matters requiring a full governance investigation
Wider context from the report “1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding;
• The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention.
• The ability of the Trust to identify matters that require a full governance investigation.
” Source location Olayemi Oluwarotimi Kodjo Kehinde · Prevention of Future Deaths report
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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 Patient Safety Incident Response Framework to guide compassionate incident responses, investigation decisions, learning and improvement.
Verbatim wording from the response “3. In 2023 the reporting and management of investigations changed with the implementation of the nationally mandated Patient Safety Incident Response Framework (PSIRF). PSIRF supports the development of an effective patient safety incident response system, that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff), and” Source location Response from NELFT
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a weekly Patient Safety Incident Group to oversee qualifying incidents and determine appropriate learning responses.
Verbatim wording from the response “4. With the implementation of PSIRF, the Trust initiated a weekly Patient Safety Incident Group (PSIG) forum chaired by the Executive Chief Nursing Officer to oversee incidents that have met the threshold for a PSIRF learning response. There are several learning responses to incidents. Decisions about the type of investigation to undertake are decided at the weekly PSIG forum, and a learning response is decided, based on the local PSIRF plan, national PSIRF recommendations via NHS England (NHSE), and following presentations from clinical staff who share immediate learning outcomes.” Source location Response from NELFT
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review historic incidents through InPhase reporting, Incident Review Group discussion, directorate oversight and, where necessary, Patient Safety Incident Group consideration of a 72-hour report.
Verbatim wording from the response “6. Once the Trust is made aware of an incident that is historic, it reviews the historic incident utilising the current process in place, which consists of reporting it as an incident on InPhase, discussion of the incident at the IRG meeting, and following further directorate oversight, and where deemed necessary, preparation of a 72-hour report for presentation at the PSIG forum. This provides a robust decision-making mechanism, ensuring that the investigation of an historic incident is treated with the same care and attention as all incidents.” Source location Response from NELFT
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28 Mar 2024 Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report Suffolk
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Concerns raised 2
Failure to define which statements are to be taken for serious patient incident investigations View source Failure to retain recordings of calls for serious patient incident investigations View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ellen Ocean WOOLNOUGH · 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
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to define which statements are to be taken for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations , are still to be introduced by the Trust.
” Source location Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
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 retain recordings of calls for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust.
” Source location Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.
Verbatim wording from the response “4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
Concerns raised 1
Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing View source
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.
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AI-generated summary
Saffra Harriett Winn · 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
On 24 July 2022, Saffra Harriett Winn was found unconscious and not breathing on pavement between two high-rise blocks of flats after falling or jumping from a window of her flat. The report raised concerns that Sheffield City Council had not risk-assessed the windows or safety latches after two tenant fatalities, and lacked a formal process for investigating and assessing risks following catastrophic injuries or deaths in its social housing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing
Wider context from the report “The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death.
More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature , together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest.
” Source location Saffra Harriett Winn · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a procedure and reporting framework for recording high-rise falls fatalities and near misses and identifying when window safety reports are required.
Verbatim wording from the response “SCC has also instigated a new procedure and reporting framework which will log all reported fatalities and near misses from falls from high rise council accommodation and guidance outlining when a safety report is required on the functionality of the windows and restrictors. This guidance is currently going through the appropriate approvals process and will again be in place by 14th June 2024. Thankfully I can report that there have been no further fatalities from falling from tower blocks since the incident in December 2023. This guidance will set out clear roles and responsibilities from the role of the Responsible Person, normally a Council Director, to who undertakes what function and when. It is also proposed that each fatality is reported to the Council’s Housing Policy Committee.” Source location Response from Sheffield City Council
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25 Mar 2024 Alexander Vitali Lyalyushko · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 4
Failure to identify un-actioned service-involvement requests in post-death incident reviews View source Insufficient learning and corrective action following deaths View source Inaccurate identification of required improvements as good practice in post-death incident reviews View source
Failure to consult families about concerns that could direct post-death incident reviews View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Vitali Lyalyushko · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexander Vitali Lyalyushko took his own life by hanging at his home on 2 January 2023, where he lived alone. A request from his GP for mental health service involvement in November 2022 was not actioned, and he was not receiving mental health services at the time of his death. The report also identified deficiencies in the initial review and incident investigation following his death, including failure to identify the unactioned request and failure to consult his family.
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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 un-actioned service-involvement requests in post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned ; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” Source location Alexander Vitali Lyalyushko · Prevention of Future Deaths report
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 Insufficient learning and corrective action following deaths
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place .
” Source location Alexander Vitali Lyalyushko · Prevention of Future Deaths report
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 Inaccurate identification of required improvements as good practice in post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice ; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” Source location Alexander Vitali Lyalyushko · Prevention of Future Deaths report
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 consult families about concerns that could direct post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review .
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” Source location Alexander Vitali Lyalyushko · Prevention of Future Deaths report
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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 the further review and addendum to incorporate newly identified information and issues from the inquest findings.
Verbatim wording from the response “record and therefore unavailable to the author of the CNR. This information became known about in January 2024 and agreed that this would be dealt with via a statement from the relevant team leader. This statement was to confirm that this referral was not available or known to the author of the CNR, confirm what had occurred, confirm what should have happened according to procedure, and what had since been put in place to reduce risk of recurrence.” Source location Response from Nottinghamshire Healthcare NHS FT
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the completed review addendum with the coroner and the deceased’s family.
Verbatim wording from the response “It was subsequently agreed at the inquest that a further review would be undertaken and addendum to the report added to take into account this information that was not known at the time of the original CNR, as well as the additional points raised within the findings and conclusion document provided to the Trust. This is being undertaken and nearing completion. We will share this once completed with you and the family of Alexander, who have been involved in the onward investigation process. Once completed we will be better sighted to understand the wider lessons learnt and actions required to mitigate future occurrence and ensure the correct oversight is deployed.” Source location Response from Nottinghamshire Healthcare NHS FT
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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.
