8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to identify falsified observation records in post-death investigation View source
This report raised 30 other concerns. They are not shown here because they do not form part of this recurring concern.
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Elise Kay Louise Sebastian · 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
Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.
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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 falsified observation records in post-death investigation
Wider context from the report “4. Mental Health Trust staff falsified Elise’s observation records and this was not identified by the Trust post-death investigation despite the availability of timings from Oxevision imaging . This matter arose in an inquest that significantly post-dated Elise’s death and there is concern that lessons had not been learned. The Trust internal investigation does not refer to this and these matters are arising with scrutiny within the inquest hearing.
” Source location Elise Kay Louise Sebastian · 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 Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.
Verbatim wording from the response “Proposed Improvement in PSIIs” Source location 2026-0078 - Response from Essex University Partnership Trust
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6 Feb 2026 Mansoor Zaman · Prevention of Future Deaths report East London
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Concerns raised 1
Patient safety investigations failing to seek treating staff recollections View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mansoor Zaman · 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
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
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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 Patient safety investigations failing to seek treating staff recollections
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff , nor communicated the findings of the report to the same staff.
” Source location Mansoor Zaman · Prevention of Future Deaths report
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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 Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Verbatim wording from the response “33. I understand it is frustrating that recollections of all staff are not always sought in PSII’s nor the findings communicated to all staff. Unfortunately, it is sometimes a balance of trying to obtain all clinician accounts (due to things such as sick leave) versus timely completion of the investigation. The same applies to feedback sessions. Though, to mitigate these issues, when staff are unable to attend feedback sessions they are routinely provided with a copy of the final report via email and asked to comment on it.” Source location 2026-0072 - Response from East London NHS Foundation Trust
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20 Jan 2026 Linda Fury · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Failure of the investigation to substantiate the finding that there was no reason to doubt capacity View source Failure of the investigation to critically analyse decisions to rescind section and discharge without trialling s17 leave View source Failure of the investigation to examine the consequences of no local bed availability for continuity of care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Pennine Care NHS Foundation Trust
Establish and ratify a subject-matter-expert framework, contact process and investigation-team mapping for patient safety investigations.
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Pennine Care NHS Foundation Trust
Refresh and operate Central Safety Summit terms of reference to oversee appropriate participation in patient safety investigations.
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Pennine Care NHS Foundation Trust
Subject investigation reports to critical scrutiny through Network Quality and Safety panels, including clinical and lived-experience perspectives.
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Pennine Care NHS Foundation Trust
Review and develop the repatriation standard operating procedure for consistent, clinically appropriate patient transfers.
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Linda Fury · 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
Linda Fury, who had a long history of severe and enduring mental illness, died at home on 3 May 2025 after being discharged from hospital following the rescinding of her detention. The report identifies concerns about the discharge decision, including insufficient consideration of family information and the failure to trial home leave or provide step-down care. It also raises concerns about the insufficient rigour of the Trust’s investigation and ward-round processes not routinely allowing families to share risk concerns privately.
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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 investigation to substantiate the finding that there was no reason to doubt capacity
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator .
” Source location Linda Fury · 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 of the investigation to critically analyse decisions to rescind section and discharge without trialling s17 leave
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled ; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator.
” Source location Linda Fury · 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 of the investigation to examine the consequences of no local bed availability for continuity of care
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally ;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator.
” Source location Linda Fury · 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 Establish and ratify a subject-matter-expert framework, contact process and investigation-team mapping for patient safety investigations.
Verbatim wording from the response “Having provided the rationale for the way in which beds are allocated, and processes in place for management and oversight of this, we acknowledge that analysis within our investigation could have been different. PCFT have identified a Trust wide risk in relation to ‘...a lack of MDT and SME involvement in patient safety investigations’. The risk specified that ‘If the correct MDT representation in investigation teams and subject matter expert involvement does not provide structured involvement in investigation, then the investigations may not capture correct learning, may have poor actions and the investigation may not lead to improved patient outcomes and appropriate response for patients, carers and staff’ (risk ID 2513. Score likelihood-3x consequence 4=12).” Source location Response from Pennine Care NHS Foundation Trust
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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 Refresh and operate Central Safety Summit terms of reference to oversee appropriate participation in patient safety investigations.
Verbatim wording from the response “The Quality teams for all investigations (Patient Safety Incident Investigation; PSII) have identified subject matter experts to support in the PSII process moving forward and this is being monitored through the Network Quality and Safety Panels and through Central Safety Summit.” Source location Response from Pennine Care NHS Foundation Trust
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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 Subject investigation reports to critical scrutiny through Network Quality and Safety panels, including clinical and lived-experience perspectives.
Verbatim wording from the response “The Trust is committed to ensuring that our investigation reports are subject to appropriate levels of critical scrutiny and this occurs at the Network Quality & Safety panels. During this process a range of professional and non-professional individuals have the opportunity to comment on the draft report. At the Mental Health Network’s Quality & Safety panel, lived experience expertise is provided by our carers representative. The panel also has a medical representative who is a consultant psychiatrist; all members of the panel provide a critical challenge to the quality of” Source location Response from Pennine Care NHS Foundation Trust
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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 and develop the repatriation standard operating procedure for consistent, clinically appropriate patient transfers.
Verbatim wording from the response “As a Trust however, we acknowledge the importance of patient choice, of carer access to their loved ones and the importance for some patients of the continuity of care. To clearly articulate the process and to deliver consistency for patients we are therefore reviewing our Standard Operating Procedures for the process of” Source location Response from Pennine Care NHS Foundation Trust
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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 Using Trust-wide beds rather than waiting for a local bed is considered safer because delayed admission and ward transfers may cause greater harm.
Verbatim wording from the response “Our patient flow team support the process for admission and will work hard to ensure a continuity of care where possible. The clinical decision to admit a patient is always based on the nature and degree of the presenting risk and that to delay an admission until a locality bed is available, may present the patient and their family an intolerable risk and further potential harms of waiting at home. Once the gatekeeper makes the referral, they will be told by patient flow team where the available bed is. Its then up to the gatekeeper to have that conversation / assessment with the patient/patients family if a local bed isn't available for them and to assess and judge on balance the admission to the local bed or another within the Trust.” Source location Response from Pennine Care NHS Foundation Trust
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Concerns raised 1
Failure to investigate incidents in accordance with Datix requirements View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lee Kenneth Eustace · 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
Lee Kenneth Eustace was admitted for treatment of oesophageal cancer and underwent a gastro-oesophagectomy with jejunostomy feeding. He developed abdominal pain, but the feed was increased and continued, and he subsequently developed jejunostomy feeding syndrome and bowel ischaemia, dying in intensive care on 1 May 2022. The report raises concerns about an insufficient and partly un followed feeding protocol, and about failures to investigate the incident, comply with the Duty of Candour, and provide relevant information to the Coroner.
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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 investigate incidents in accordance with Datix requirements
Wider context from the report “I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirement to do so under Datix . I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths.
” Source location Lee Kenneth Eustace · 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 Report identified care concerns through the incident reporting system and provide Duty of Candour, investigation and learning.
Verbatim wording from the response “• If any triggers are identified, a Structured Judgement Review (SJR) is undertaken by an independent clinician.” Source location Response from University Hospitals Plymouth NHS Trust
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11 Dec 2025 Mrs Ashana Charles · Prevention of Future Deaths report South London
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Concerns raised 1
Inadequate investigation of deaths potentially associated with IV feeding View source
This report raised 7 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.
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Mrs Ashana Charles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.
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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 Inadequate investigation of deaths potentially associated with IV feeding
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation .
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Source location Mrs Ashana Charles · Prevention of Future Deaths report
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Concerns raised 1
Failure to investigate what went wrong and why between treating and administration teams 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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Lynn SILCOCK · Prevention of Future Deaths report
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Report summary
Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.
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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 investigate what went wrong and why between treating and administration teams
Wider context from the report “(4) No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams .
” Source location Lynn SILCOCK · 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 Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Verbatim wording from the response “The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter.” Source location Response from Shrewsbury and Telford Hospital
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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 Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Verbatim wording from the response “The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised with cardiology advising these should be completed first then cardiology would continue the process to investigate the aortic stenosis. On review it is clear there was no expectation that the gastroenterology team would be responsible for following up the referral to cardiology once Ms Silcock’s endoscopy investigations were completed.” Source location Response from Shrewsbury and Telford Hospital
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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 concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
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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 Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
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15 Oct 2025 Malik BUNTON · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Delays and obstructions in gathering evidence from key witnesses View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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
Ministry of Defence
Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.
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Ministry of Defence
Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.
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Malik BUNTON · 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
Malik Bunton was found suspended from a ligature on 17 July 2023, and his death was confirmed at the scene. The inquest concluded that he died as a result of suicide, following earlier incidents involving suicidal intent and self-harm concerns. The principal concerns related to insufficient inquiry into an earlier incident, weaknesses in the Defence Medical Service Clinical Care Review process, and delays or obstructions in gathering important 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 Delays and obstructions in gathering evidence from key witnesses
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses . This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
” Source location Malik BUNTON · 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 Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.
Verbatim wording from the response “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.” Source location Response from Ministry of Defence
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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 Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.
Verbatim wording from the response “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.” Source location Response from Ministry of Defence
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14 Oct 2025 Mohan Singh Hothi · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mohan Singh Hothi · 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
Mohan Singh Hothi was admitted to hospital after a fall at home and was found to have a catastrophic subdural haematoma; he died later that day. Concerns included the Trust not investigating two serious injuries from previous unwitnessed falls through its Patient Safety Framework, and vague and incomplete evidence about reflection and remediation.
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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 assess serious unwitnessed falls for investigation through the Patient Safety Framework
Wider context from the report “1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice.
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
” Source location Mohan Singh Hothi · 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 Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Verbatim wording from the response “2. Every reported fall incident is discussed at the weekly Geriatrics Care Group incident review meeting, chaired by the Quality and Safety Advisor, to determine preventability, assess any harm sustained and share learning across the Care Group.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Verbatim wording from the response “4. All inpatient falls within the Geriatrics Care Group are reported to the Trust’s Quality Governance and Steering Group (QGSG), with any falls resulting in serious harm detailed. Decisions regarding escalation for a learning response are formally recorded and reported to the Trust Board.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Verbatim wording from the response “The investigations conducted under incident reference numbers ████████ concluded that both falls were unpreventable. Mr Hothi was assessed as having full mental capacity, displayed no signs of confusion, and was able to understand and follow instructions. Under these circumstances, patients are not provided with constant supervision, as they are deemed capable of communicating their care needs to the nursing staff. Moreover, continuous supervision would require the implementation of a Deprivation of Liberty Safeguards (DoLS) authorisation, for which Mr Hothi did not meet the criteria.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Verbatim wording from the response “In accordance with the Patient Safety Incident Review Framework (PSIRF) and the Trust PSIRF plan, incidents are referred for a learning response when the contributing factors are not well understood or when there is potential for significant local or organisational learning. Following the review of incidents ████████, it was determined that the underlying factors were clearly understood – specifically that Mr Hothi chose to mobilise independently without awaiting assistance from nursing staff.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Verbatim wording from the response “• The factors contributing to Mr Hothi’s falls were known and understood; therefore, no further investigation was required. Ongoing actions to manage these factors were already in place.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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2 Oct 2025 Beatrice Smith · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Lack of effective internal investigation and organisational learning from safeguarding incidents View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Harbour Healthcare Ltd.
Complete a Serious Untoward Incident root cause analysis with Human Resources support.
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Harbour Healthcare Ltd.
Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
View source
Harbour Healthcare Ltd.
Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
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Harbour Healthcare Ltd.
Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
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Harbour Healthcare Ltd.
Cascade Riverside Court’s inquest outcome and lessons learned across the company.
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AI-generated summary
Beatrice Smith · 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
Beatrice Smith, who was living at Riverside Court Care Home, developed seriously deteriorating leg and heel ulcers after 15 April 2025. Specialist attention was not sought and the ulcer was not always properly dressed; she developed sepsis, was admitted to hospital on 23 April 2025, and died that day. Concerns included the apparent absence of an effective internal investigation and of additional staff training or guidance, creating risks of missed learning and repeated inadequate care.
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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 effective internal investigation and organisational learning from safeguarding incidents
Wider context from the report “(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
” Source location Beatrice Smith · 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 a Serious Untoward Incident root cause analysis with Human Resources support.
Verbatim wording from the response “Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources.” Source location Response from Harbour Healthcare Limited
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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 Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
Verbatim wording from the response “10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas” Source location Response from Harbour Healthcare Limited
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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 Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
Verbatim wording from the response “11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting” Source location Response from Harbour Healthcare Limited
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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 Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
Verbatim wording from the response “As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroners inquest relating to a home and then the associated lessons learned.” Source location Response from Harbour Healthcare Limited
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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 Cascade Riverside Court’s inquest outcome and lessons learned across the company.
Verbatim wording from the response “15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025” Source location Response from Harbour Healthcare Limited
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29 Sep 2025 Mohammad Ali Asghar · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to undertake a patient safety framework investigation when concerns and review triggers arise View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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
Barts Health NHS Trust
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
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AI-generated summary
Mohammad Ali Asghar · 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
Mohammad Ali Asghar was admitted to hospital with worsening shortness of breath and fluid overload, and later suffered a cardiac arrest after catheter removal following haematuria and clots. The principal concerns were failures in Trust governance and incident-reporting processes, including the failure to identify and investigate the case through the Patient Safety Framework despite concerns about an iatrogenic injury and a court direction for review.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake a patient safety framework investigation when concerns and review triggers arise
Wider context from the report “2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred .
” Source location Mohammad Ali Asghar · 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 Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Verbatim wording from the response “To support this, Barts Health is in the process of commissioning an Independent Review of our governance processes with comprehensive terms of reference which will include review of our decision-making at Patient Safety Incident Review Meeting (PSIRM) relating to the learning responses under PSIRF. This review will examine the criteria and thresholds used to determine when a PSII or alternative learning response is required, ensuring these are clearly defined, consistently applied, and responsive to emerging information or stakeholder concerns.” Source location Response from Barts Health NHS Foundation Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.