Recurring concern

Inadequate safety incident investigations

First to latest report 13 Dec 2008 — 25 Jun 2026

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

What this concern includes

Includes initiation, evidence gathering, witness testing, factual accuracy, analysis, timeliness, investigator competence and reporting within investigations of deaths, serious incidents and patient, resident or operational safety events.

What is not included
  • Police, conduct, regulatory or other investigations not directed at organisational safety learning
  • Failure to implement an unrelated safety action not arising from an incident investigation
  • Generic governance failures not directly affecting a safety incident investigation or its learning process
  • Excludes downstream dissemination, learning and corrective-action controls once the investigation findings have been established.

Reports and published responses 244 reports

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

  1. London Greater (East)

    AI-generated summary

    Joshua Knox-Hooke · 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

    Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to identify and investigate matters meeting Serious Incident criteria

    Wider context from the report

    “4. The North Middlesex University Hospital NHS Trust did not consider this matter to fall within their criteria for a Serious Incident. No Serious Incident Investigation was carried out. ”

    Source location

    Joshua Knox-Hooke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish joint serious incident investigations with the mental health trust for future incidents involving hospital-provided care.

    Verbatim wording from the response

    “Finally the Trust notes your criticism that the Trust did not consider the patient’s death to be a Serious Incident and did not undertake a Serious Incident Investigation. The Trust was disappointed with this criticism as North Middlesex Hospital was not informed by Barnet, Enfield & Haringey Mental Health Trust that this patient had been found dead, nor was North Middlesex Hospital NHS Trust invited to participate in the BEH MHT serious incident investigation as it would expect to be given the circumstances. As a result, our Medical Director has discussed this with the Medical Director at BEH MHT so that future serious incident investigations undertaken by BEH MHT that involve aspects of care provided by North Middlesex Hospital undergo a joint investigation with the expectations set out in NHS England’s Serious Incidents Requiring Investigation Framework.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Agree a new incident management pathway with the mental health trust clinical lead.

    Verbatim wording from the response

    “A new incident management pathway has subsequently been agreed with the BEH MHT clinical lead for North Middlesex Hospital. The Trust has subsequently undertaken its own Serious Incident investigation into Mr Knox-Hooke’s death by reviewing the original Serious Incident investigation undertaken by Barnet, Enfield & Haringey Mental Health Trust and ensuring it captures learning for North Middlesex Hospital.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake a Serious Incident investigation into the death by reviewing the mental health trust’s investigation and capturing learning for the hospital.

    Verbatim wording from the response

    “A new incident management pathway has subsequently been agreed with the BEH MHT clinical lead for North Middlesex Hospital. The Trust has subsequently undertaken its own Serious Incident investigation into Mr Knox-Hooke’s death by reviewing the original Serious Incident investigation undertaken by Barnet, Enfield & Haringey Mental Health Trust and ensuring it captures learning for North Middlesex Hospital.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Danny Sweet · 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

    Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Incomplete serious incident review lacking formal interviews of relevant clinicians

    Wider context from the report

    “A final matter that came out of the inquest was that the Serious Incident Report was incomplete. In particular, neither ████████ nor ████████ had been formally interviewed as part of the review process. You may feel that there would be merit in getting the respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT) together to see if there are any lessons to be learned. ”

    Source location

    Danny Sweet · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure all key clinicians within investigation terms of reference participate in future Serious Incident investigations.

    Verbatim wording from the response

    “The Trust acknowledges that the Serious Incident Report is incomplete. There are learning points for the Trust in relation to Serious Incident Investigations and the Trust’s Director of Quality and Governance/Executive Nurse, ████████ will take this forward. We will ensure that in the future all key clinicians, within the Terms of Reference, are involved in future investigations. We have also identified the importance of providing feedback to staff interviewed for the purposes of the investigation.”

    Source location

    2016-0275-Response-by-Cornwall-NHS-Trust
    Page 2 · response
    Published 29 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the Trust’s Serious Incident investigation process.

    Verbatim wording from the response

    “In summary there will be action taken by the Trust by way of a Learning from Experience Meeting to consider ways of developing a pathway; how to engage friends and family and to allow a further period of reflection. It is expected that an action plan will be developed at the Learning from Experience meeting. There will also be a review of the clinical risk assessments of people who present with suicidal thoughts or acts by the end of February 2017 and we will review the Trust’s Serious Investigation process.”

    Source location

    2016-0275-Response-by-Cornwall-NHS-Trust
    Page 3 · response
    Published 29 July 2016

    Open published response

  3. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure hospital investigations include appropriate clinical expertise

    Wider context from the report

    “7. The hospital investigation into the circumstances surrounding the death was conducted by a ward manager. The thinking behind having a senior nurse explore questions of nursing care is obvious. However, the report also commented on aspects of medical care that the report author freely admitted in court were outside her area of expertise. In terms of learning lessons for the future, this seems sub optimal. Clinicians giving evidence disagreed with some of the report’s conclusions, but I was not able to explore those areas with the true originator, because the views had come from a consultant who the author had consulted informally. The report was not recorded as being co-authored, and the doctor who had been asked for his view was not an oncologist. The author thought on reflection that an oncologist would have been better placed to comment on the medical management. ”

    Source location

    Margaret Emily TUCK · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Buckinghamshire

    AI-generated summary

    Stephen John Bird · 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

    Stephen John Bird underwent surgery for an Achilles tendon injury on 6 May 2016 and died at home on 11 May 2016. The recorded cause of death was pulmonary embolism due to deep vein thrombosis following recent surgery. Concerns included incomplete, inconsistent or conflicting records and an investigation report containing assumptions that conflicted with documentary records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure Significant Clinical Incident Investigation reports are based on documentary records rather than conflicting assumptions

    Wider context from the report

    “(2) Evidence given regarding the investigation by the hospital into Mr Bird’s death and the preparation of a draft Significant Clinical Incident Investigation (SCII) Report (disclosed as part of the Inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the Inquest hearing. It was indicated during the hearing that the hospital places reliance upon SCII reports as part of a learning process. ”

    Source location

    Stephen John Bird · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete a BMI Root Cause Analysis of the incident and provide the finalised report.

    Verbatim wording from the response

    “In response to these concerns the initial investigation report has been reviewed and a RCA has been completed. We enclose a copy of the finalised RCA.”

    Source location

    2016-0265-Response-by-South-Buckinghamshire-Hospitals
    Page 2 · response
    Published 22 July 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Investigation reports remain in draft format until the Inquest concludes, preventing finalisation while further issues may be identified.

    Verbatim wording from the response

    “Please be advised that reports concerning the investigation of the death of an unexpected patient remain in draft format pending conclusion of the Inquest to ensure all issues identified at the Inquest can be addressed in the report.”

    Source location

    2016-0265-Response-by-South-Buckinghamshire-Hospitals
    Page 2 · response
    Published 22 July 2016

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Olive Wilmott · 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

    Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to effectively investigate suspected pushing incidents

    Wider context from the report

    “1. That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of the circumstances was made at the time and no Safeguarding referral was made. ”

    Source location

    Olive Wilmott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Nadim Muzzfar BUTT · 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

    Nadim Muzzfar BUTT died on 5 September 2014 after complications following laparoscopic gastric bypass surgery, including small bowel obstruction, systemic inflammatory response syndrome and multi-organ failure. The report raised concerns that the hospital review was not escalated to a serious untoward incident or root cause analysis, and that no consultant-led out-of-hours on-call rota was in place for postoperative patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to escalate matters for comprehensive serious incident or root cause review

    Wider context from the report

    “1, Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination. ”

    Source location

    Nadim Muzzfar BUTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. County Durham and Darlington

    AI-generated summary

    Mr Matthews · Prevention of Future Deaths report

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

    Report summary

    Mr Matthews, who had pneumoconiosis and COPD, was admitted to hospital after being found collapsed and later suffered further cardiac arrests before dying on 19 February 2016. The principal concerns were that oxygen was not prescribed or recorded at the required rate, and that there was no system to ensure the oxygen concentrator was working correctly or that damage to it was promptly reported and investigated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to investigate oxygen concentrator incidents

    Wider context from the report

    “(4) The Clinical Engineering Team Leader and the manufacturer concur that the damage to the oxygen concentrator was caused by an accident and that the damage was not responsible for the death. Nevertheless, I am concerned that the incident was not reported to the manufacturer at the time and that no investigation was carried out. The Trust has subsequently reviewed its incident reporting policy and the manufacturer has reviewed its own policy. ”

    Source location

    Mr Matthews · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue monitoring the situation and investigate further adverse incidents involving the flowmeter.

    Verbatim wording from the response

    “The MHRA is continuing to monitor this situation and will investigate any further incidents that we receive.”

    Source location

    2016-0276-Response-by-Medicines-and-Healthcare-Products-Regulatory-Agency
    Page 3 · response
    Published 26 July 2016

    Open published response

  8. Leicester City and South Leicestershire

    AI-generated summary

    Ahmedreza Fathi · 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

    Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to investigate suspected overdose events and apply learning outcomes

    Wider context from the report

    “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  9. Manchester City

    AI-generated summary

    Milly ZEMMEL · 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

    Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate internal investigation of failures in basic medical care

    Wider context from the report

    “1. The Trust’s own internal investigative procedures were demonstrably inadequate because the internal hospital investigation did not fully and properly identify the gross failure to provide the deceased with the basic medical care which her condition obviously required on the morning of 1 March 2015. The full particulars only became apparent when evidence was heard at the inquest and the records were checked. The gravity of the failings in care had not been properly identified. ”

    Source location

    Milly ZEMMEL · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise and launch the Incident Reporting and Investigation Policy and require independent investigation teams for serious incidents.

    Verbatim wording from the response

    “It was recognised early in 2015 that the Trust need to make improvements in how investigations were conducted within the organisation. An external review of serious incident investigations was commissioned by the former Chief Executive and following this review the Trust instigated a number of actions:”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 1 · response
    Published 6 April 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train 103 staff, including senior clinicians and managers, in root cause analysis.

    Verbatim wording from the response

    “• A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers, were trained during 2015/16. In addition the Trust delivered training on Duty of Candour (being open) to ensure that patients and families receive support and feedback when a serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue the internal investigation training programme throughout 2016/17.

    Verbatim wording from the response

    “• A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers, were trained during 2015/16. In addition the Trust delivered training on Duty of Candour (being open) to ensure that patients and families receive support and feedback when a serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop an investigation toolkit covering investigation processes and report preparation.

    Verbatim wording from the response

    “• To accompany the RCA training programme the Clinical Governance team have also developed an investigation toolkit that covers all aspects of investigations and advice on preparing and writing investigation reports.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

  10. Staffordshire South

    AI-generated summary

    Angela Catherine Brealey · 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

    Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Serious incident reviews failing to identify treatment concerns

    Wider context from the report

    “(3) Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about Angela’s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports? ”

    Source location

    Angela Catherine Brealey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and amend the Serious Incident Review Process, with structured internal and external governance arrangements.

    Verbatim wording from the response

    “Thank you for your comments regarding the overall helpfulness of the Serious Incident Review Process. I can confirm that since the time of this specific Serious Incident Review, the process has been reviewed and amended. The Serious Incident Review Process follows a structured and robust process with internal and external governance arrangements in place.”

    Source location

    2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
    Page 3 · response
    Published 24 December 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Employ a full-time Serious Incident Review Co-ordinator and Administrator to support investigations and improve the quality of serious incident reports and reviews.

    Verbatim wording from the response

    “The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator to support Investigating Officers in the review process. The Serious Incident Review Co-ordinator works within the Trust’s Quality and Risk Department to help improve processes that are used to ensure the quality production of reports relevant to serious incidents. They support Investigating Officers in the completion of Serious Incident Reports and Significant Event Reviews and are responsible for the completion of Chronological and concise reports. The Serious Incident Review Co-ordinator supports and encourages an open and fair approach to incident identification and investigation, supported by a learning culture.”

    Source location

    2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
    Page 3 · response
    Published 24 December 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require commissioners to conduct a challenge review before signing serious incident reports for release.

    Verbatim wording from the response

    “In addition the reports now go through an additional governance process in that our commissioners carry out a challenge review prior to signing the report off for release.”

    Source location

    2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
    Page 3 · response
    Published 24 December 2015

    Open published response

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

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Data last updated 7 September 2026