Recurring concern

Inadequate safety incident investigations

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First reported 13 Dec 2008•Latest report 25 Jun 2026

Definition

What this concern includes

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

Not included

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

Reports: 244
Individual concerns: 316
Date range: 2008–2026
Stated actions: 447

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care31

Care Quality Commission21

NHS England20

Betsi Cadwaladr University LHB11

Barking, Havering and Redbridge University Hospitals NHS Trust10

Barts Health NHS Trust8

Greater Manchester Mental Health NHS Foundation Trust8

Pennine Care NHS Foundation Trust7

Essex Partnership University NHS Foundation Trust6

Nottinghamshire Healthcare NHS Foundation Trust5

Tameside and Glossop Integrated Care NHS Foundation Trust5

Tees, Esk and Wear Valleys NHS Foundation Trust5

Health and Safety Executive4

Medicines and Healthcare products Regulatory Agency4

NHS Greater Manchester Integrated Care Board4

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

19 Oct2015
Inner North London
Concerns raised1
1. Failure to include involved registrars’ input in untoward incident investigations
This report raised 6 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Vasilis KTORAKIS · 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

Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.

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 include involved registrars’ input in untoward incident investigations
Wider context from the report
“4. The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for the registrar. ”
Source location
Vasilis KTORAKIS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Jun2015
Manchester South
Concerns raised1
1. Failure to test care home employees’ accounts during investigations
This report raised 4 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sidney Barnett · 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

Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to test care home employees’ accounts during investigations
Wider context from the report
“4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated. 5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened. ”
Source location
Sidney Barnett · Prevention of Future Deaths report
Page 1 · concerns
Open source report
20 May2015
West Sussex
Concerns raised1
1. Failure to undertake a serious incident review after a patient death shortly after discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Contact provider organisations early and agree responsibility for reporting and serious-incident investigations.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Responsibility for reporting and leading the serious incident investigation was assigned to the lead provider, while the Trust expected to participate.
  Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibility
AI-generated summary

Mrs Wanda Stachurska · 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 Wanda Stachurska was found deceased on 18 November 2014 after being discharged from hospital the previous evening following a suicide attempt involving an overdose and attempted hanging. Concerns included the quality of the mental health risk assessment, including the use of an untrained security guard as an interpreter and the failure to communicate relevant information about the earlier attempted hanging. The report also raised concerns that neither Trust conducted a serious incident review after her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake a serious incident review after a patient death shortly after discharge
Wider context from the report
“(2) Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge. (a) An opportunity to learn lessons from the above events has hence been delayed and potentially been lost; (b) To decline to conduct a serious incident review because of a pre-determined opinion that there had been not been any omissions or shortcomings by the organisation might reflect a misunderstanding by SASH of the purpose and value of such investigations. ”
Source location
Mrs Wanda Stachurska · 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
Contact provider organisations early and agree responsibility for reporting and serious-incident investigations.

Verbatim wording from the response
“In this instance at the time of the incident coming to light, we believed that the lead provider in the care at the time of the death was going to report and lead the investigation process and as due process we would have taken part in the investigation. Unfortunately in this instance all the communication regarding the responsibility for the serious incident investigation was managed through the HM Coroner’s Office instead of directly with our acute care provider colleagues as per our general practice. We have taken steps to ensure that when such issues arise we as providers make contact with each other early and agree reporting and investigation responsibilities.”

Source location
2015-0199-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 2 · response
Published 20 May 2015
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
Responsibility for reporting and leading the serious incident investigation was assigned to the lead provider, while the Trust expected to participate.

Verbatim wording from the response
“In this instance at the time of the incident coming to light, we believed that the lead provider in the care at the time of the death was going to report and lead the investigation process and as due process we would have taken part in the investigation. Unfortunately in this instance all the communication regarding the responsibility for the serious incident investigation was managed through the HM Coroner’s Office instead of directly with our acute care provider colleagues as per our general practice. We have taken steps to ensure that when such issues arise we as providers make contact with each other early and agree reporting and investigation responsibilities.”

Source location
2015-0199-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 2 · response
Published 20 May 2015
Open published response
19 May2015
Derby and Derbyshire
Concerns raised3
1. Inaccuracies in internal investigation reports
2. Insufficient and perfunctory investigations of patient deaths
3. Failure to interview key witnesses during investigations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Rewrite and implement the serious incident investigation policy with guidance on reporting, investigation, best practice, system failures and record-keeping standards.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Introduce an Executive-led Serious Incident Review Panel to scrutinise investigation reports and action plans and require clinical leads to report changes and learning.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
3. Action
  Train senior officers across all divisions in root-cause analysis and incident investigation through external facilitation.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
1. Action
  Require Directors to review each serious incident and assign an investigation level, team and relevant professional advice.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Sheila Johnson · Prevention of Future Deaths report

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

Report summary

Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.

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
Inaccuracies in internal investigation reports
Wider context from the report
“(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”
Source location
Sheila Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient and perfunctory investigations of patient deaths
Wider context from the report
“(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”
Source location
Sheila Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to interview key witnesses during investigations
Wider context from the report
“(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”
Source location
Sheila Johnson · 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
Rewrite and implement the serious incident investigation policy with guidance on reporting, investigation, best practice, system failures and record-keeping standards.

Verbatim wording from the response
“In relation to your particular concerns regarding the quality of the internal investigation undertaken at this time, the Trust’s processes have been revised significantly and beyond all recognition. The current policy for the management of serious incidents including their investigation has been rewritten and implemented. The policy provides clear guidance to Trust staff in relation to incident reporting and the investigation process, with the aim of improving the quality of the Trust’s investigations. We have had this monitored by the CQC and CCG and reported to external oversight groups.”

Source location
2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 19 May 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
Introduce an Executive-led Serious Incident Review Panel to scrutinise investigation reports and action plans and require clinical leads to report changes and learning.

Verbatim wording from the response
“We have also introduced improvements to the process for internal review of serious incident reports. There is now an Executive led Serious Incident Review Panel which reviews all serious incident investigation reports and action plans and scrutinises and challenges them, providing feedback to the investigation teams when further clarity is required. The panel also require that responsible nursing and medical leads attend the meeting to feed back what changes have been made and what lessons have been learnt from investigations.”

Source location
2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 19 May 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
Train senior officers across all divisions in root-cause analysis and incident investigation through external facilitation.

Verbatim wording from the response
“We recognise that staff undertaking incident investigations need to be appropriately trained. Since the investigation into Mrs. Johnson’s death the Trust has invested significantly in additional training provided by an external facilitator. This has delivered root cause analysis and investigation training across all divisions of the Trust, the most recent training taking place in March of this year. More than 75 senior officers have been trained in RCA. This has underpinned the revised policy to ensure investigations are more robust and recommendations are acted upon and patient care and safety is improved.”

Source location
2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 19 May 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 Directors to review each serious incident and assign an investigation level, team and relevant professional advice.

Verbatim wording from the response
“All serious incidents are reviewed by Directors who assign a level of investigation and an investigation team to each serious incident, consisting either of appropriate individuals from the Trust or where relevant external independent persons. Professional advice relevant to the specialty is now obtained.”

Source location
2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 19 May 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.

Verbatim wording from the response
“The auditors concluded in their report dated 10th March 2015 that the serious incident processes provided significant assurance to the Trust that systems and processes were in place.”

Source location
2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 19 May 2015
Open published response
6 Mar2015
Central Lincolnshire
Concerns raised3
1. Failure to maintain independence between clinical responsibility and SUI investigation
2. Failure to identify and address inadequacies in an operating surgeon's statement and SUI
3. Failure to read source statements before signing off an SUI Report
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Strengthen serious-incident investigations through revised governance processes, independent investigator requirements, weekly senior oversight, external submission and Trust Board reporting.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progress
AI-generated summary

Thor Harrison Dalhaug · 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

Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain independence between clinical responsibility and SUI investigation
Wider context from the report
“(V) The fact that the consultant ultimately responsible for Thor was also charged with undertaking the SUI Report into his death. Further, that the consultant signed off the original SUI Report without having read any of the statements referred to in that report. Please disclose the policy or means by which it has been made clear that this should not happen in the future. ”
Source location
Thor Harrison Dalhaug · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify and address inadequacies in an operating surgeon's statement and SUI
Wider context from the report
“(IX) The fact that there was a failure to recognise the inadequacy of the operating surgeon's original statement and SUI and that these inadequacies were not addressed until I directed the Trust to obtain a full statement and undertake a comprehensive SUI. ”
Source location
Thor Harrison Dalhaug · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to read source statements before signing off an SUI Report
Wider context from the report
“(V) The fact that the consultant ultimately responsible for Thor was also charged with undertaking the SUI Report into his death. Further, that the consultant signed off the original SUI Report without having read any of the statements referred to in that report. Please disclose the policy or means by which it has been made clear that this should not happen in the future. ”
Source location
Thor Harrison Dalhaug · 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
Strengthen serious-incident investigations through revised governance processes, independent investigator requirements, weekly senior oversight, external submission and Trust Board reporting.

Verbatim wording from the response
“This was not appropriate and should not have happened. Since 2014 the Trust has significantly reviewed and changed its processes relating to investigations (please see Appendix 2).”

Source location
2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Page 5 · response
Published 6 March 2015
Open published response
27 Jan2015
Surrey
Concerns raised1
1. Failure of SI reports to consider dehydration as a possible cause of acute renal failure
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Operate a multidisciplinary Serious Incident Review Group meeting fortnightly to review investigations and reports before closure.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated completed
Respondent positions 1
1. Position
  The Trust disputes that its investigation failed to recognise dehydration as a possible cause of acute kidney injury.
  Stated by Survey and Sussex NHS Healthcare NHS TrustDisputes the concern
AI-generated summary

Susanna Geraty · 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

Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of SI reports to consider dehydration as a possible cause of acute renal failure
Wider context from the report
“6. Failure of the SI report to consider or acknowledge dehydration as a possible cause of acute renal failure ”
Source location
Susanna Geraty · 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
Operate a multidisciplinary Serious Incident Review Group meeting fortnightly to review investigations and reports before closure.

Verbatim wording from the response
“The Trust now has a Serious Incident Review Group (appendix 7) made up of multi-disciplinary members which meets fortnightly to review SI investigations and their reports. This presents an opportunity for the investigation team to give a thorough explanation of the investigations findings and a chance to review the report before closure.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 5 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust disputes that its investigation failed to recognise dehydration as a possible cause of acute kidney injury.

Verbatim wording from the response
“As described above, the SI report was produced many months before the expert suggested dehydration. The SI report had been unable to identify the cause of the hyperkalaemia, in a case which was complicated by a lack of any clinical signs and symptoms of dehydration either in life or at post mortem, and in a patient who had been conscious and documented to be eating and drinking well. The Trust does not agree that the investigation failed to recognise dehydration as the cause of AKI. The consultant who led the investigation felt that there were multiple causes in the deterioration in renal function which he considered at the time, including inadequate fluids, but accepts that this was not explicitly detailed in the report.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 4 · response
Published 27 January 2015
Open published response
19 Jan2015
Bedfordshire and Luton
Concerns raised1
1. Failure to conduct a formal Serious Incident Investigation
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Simon Robert ALLISTON · 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

Simon Robert ALLISTON lived alone and was found deceased in his flat after neighbours had not seen him for approximately a week; paramedics confirmed his death. The concerns included his discharge from mental health services without a formal handover, despite the Community Team considering that he still needed support, with no recorded reason for discharge and no formal Serious Incident Investigation after his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to conduct a formal Serious Incident Investigation
Wider context from the report
“(4) That following the death of Simon Alliston there was no formal Serious Incident Investigation ”
Source location
Simon Robert ALLISTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Nov2014
County Durham and Darlington
Concerns raised1
1. Failure of internal methadone-related death inquiries to draw on external research
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Peter Greenfield · Prevention of Future Deaths report

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

Report summary

David Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of internal methadone-related death inquiries to draw on external research
Wider context from the report
“1. Not everyone involved in his care was experienced in dealing with patients who had both drug and alcohol problems and the risks of respiratory depression in patients such as the deceased were not fully appreciated. The internal enquiry undertaken by The Priory following the deceased’s death took into account experience and opinions of people within the organisation but did not draw upon research undertaken outside the organisation on the question of sudden and unexpected deaths of people taking prescribed methadone. A re-training programme had been introduced by The Priory following this death but it would seem that there remains a lack of a detailed appreciation of the risks involved of death of patients in receipt of methadone and of patients with the particular characteristics of the deceased and therefore until that understanding and appreciation of risk has been determined training which has already being investigated cannot properly deal with issues which have yet to be identified. It is therefore believed that a further review of such risk and risk management policies needs to be considered with suitable re-training introduced thereafter. ”
Source location
David Peter Greenfield · Prevention of Future Deaths report
Page 1 · concerns
Open source report
18 Sep2014
Leicester City and South Leicestershire
Concerns raised1
1. Failure to produce accurate and reliable investigation reports
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Establish named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.
  Stated by University Hospitals of Leicester NHS TrustStated completed
2. Action
  Purchase and provide tiered external RCA training for investigation leads, senior safety investigators and RCA Chairs.
  Stated by University Hospitals of Leicester NHS TrustStated completed
3. Action
  Provide senior scrutiny of events causing avoidable death or harm and identify root causes, themes and required safety workstreams.
  Stated by University Hospitals of Leicester NHS TrustStated planned
AI-generated summary

Janet Doreen Goodacre · 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

Janet Doreen Goodacre, aged 88, was admitted to Leicester Royal Infirmary on 1 May 2013 and died there on 21 May 2013 after developing a gastrointestinal bleed while receiving warfarin, deltaparin and aspirin. The report raised concerns that the Trust’s investigation report was factually incorrect and flawed, that its identified root causes were wrong, and that the Trust did not communicate these shortcomings or revisit the report before the inquest.

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 produce accurate and reliable investigation reports
Wider context from the report
“I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors. ”
Source location
Janet Doreen Goodacre · 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 named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.

Verbatim wording from the response
“The Trust continually works to improve the quality of the investigations of the RCA reports and we have recently introduced three further measures to assist with this.”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 1 · response
Published 18 September 2014
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
Purchase and provide tiered external RCA training for investigation leads, senior safety investigators and RCA Chairs.

Verbatim wording from the response
“The Trust continually works to improve the quality of the investigations of the RCA reports and we have recently introduced three further measures to assist with this.”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 1 · response
Published 18 September 2014
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
Provide senior scrutiny of events causing avoidable death or harm and identify root causes, themes and required safety workstreams.

Verbatim wording from the response
“3. The Trust has established a new ‘Adverse Events Committee’, reporting to the Executive Quality Board, to review all serious untoward events (SUIs).”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 2 · response
Published 18 September 2014
Open published response
9 Sep2014
South and West Cambridgeshire
Concerns raised1
1. Failure to investigate serious incidents and prevent recurrence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Revise the Trust’s Serious Incident process within the wider quality-improvement programme.
  Stated by North West Anglia NHS Foundation TrustStated in progress
AI-generated summary

Anne Elizabeth Sandever · 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

Anne Elizabeth Sandever, a diabetic woman with acute on chronic renal failure, was admitted to hospital on 3 February 2014, deteriorated after transfer to Walnut ward, and died on 6 February 2014. The concerns included gaps in nursing and medical observation, poor communication and handover about her diabetes, lack of intravenous fluids despite renal failure, and insufficient investigation 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 investigate serious incidents and prevent recurrence
Wider context from the report
“(4) There has been no SUI inquiry and the hospital has not investigated this sufficiently to ensure that this does not recur and has not taken the necessary steps to assure me of this. ”
Source location
Anne Elizabeth Sandever · Prevention of Future Deaths report
Page 1 · 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 the Trust’s Serious Incident process within the wider quality-improvement programme.

Verbatim wording from the response
“The Trust’s Serious Incident process is also being revised as part of a wider quality improvement programme.”

Source location
2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to include involved registrars’ input in untoward incident investigations

Concerns raised1

Failure to test care home employees’ accounts during investigations

Concerns raised1

Failure to undertake a serious incident review after a patient death shortly after discharge

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

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

Concerns raised3

Inaccuracies in internal investigation reports

Insufficient and perfunctory investigations of patient deaths

Failure to interview key witnesses during investigations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

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

Concerns raised3

Failure to maintain independence between clinical responsibility and SUI investigation

Failure to identify and address inadequacies in an operating surgeon's statement and SUI

Failure to read source statements before signing off an SUI Report

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

Concerns raised1

Failure of SI reports to consider dehydration as a possible cause of acute renal failure

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

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

Concerns raised1

Failure to conduct a formal Serious Incident Investigation

Concerns raised1

Failure of internal methadone-related death inquiries to draw on external research

Concerns raised1

Failure to produce accurate and reliable investigation reports

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 1

Actions described in response 1

Actions described in response 1

Respondent positions 1

Actions described in response 3