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

Distinct published reports

Individual concerns
316

A report can raise multiple concerns

Date range
2008–2026

First to latest report issue date

Stated actions
447

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Ian Jacka · 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

    Ian Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex 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 investigate unexplained omissions in critical incident records and handover

    Wider context from the report

    “(4) The error of omission was unexplained and has not been investigated by the NHS. The evidence regarding the error of omission came to light after the completion of the NHS investigation into Ian’s death. The Consultant Anaesthetist involved in Ian’s operation discovered the fact of the critical incident of 5 June 2022 on a later examination of ventilator data. The data indicated that Ian deteriorated significantly, that he was close to a cardiac arrest and the critical care team saved his life. ”

    Source location

    Ian Jacka · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.

    Verbatim wording from the response

    “The documentation in relation to the critical incident is both comprehensive and appropriate. Mr Jacka deteriorated, requiring intubation and ventilation as a result of type 2 respiratory failure caused by his significant chest and spinal injuries. His blood oxygen saturations and blood pressure fell significantly but were rapidly restored to normal upon the arrival of the ICU registrar with simple interventions after a relatively short period of time. The lowest oxygen saturations and blood pressure values were recorded in the notes by the ICU nurse at the time. Mr Jacka was anaesthetised and intubated – this was technically challenging and represented a difficult airway, but Mr Jacka remained stable throughout this process with no further drop in oxygen levels.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 2 · response
    Published 18 December 2023

    Open published response

  2. Inner North London

    AI-generated summary

    Sarah CHAPPELL · 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

    Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a proper trust investigation after a patient death

    Wider context from the report

    “6. This death occurred almost six months ago, but no proper trust investigation has taken place, no changes in policies or procedures has been agreed, and the systems at UCLH remain largely what they were on the day that Sarah Chappell died. ”

    Source location

    Sarah CHAPPELL · 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

    Complete a cardiac-arrest rapid review and produce a detailed after-action improvement plan.

    Verbatim wording from the response

    “A 72 hour cardiac arrest rapid review was undertaken on 3rd July 2023. This culminated in an after-action review with a robust and detailed action plan. There was a delay to producing the action plan (October 2023) and we recognise this as a concern.”

    Source location

    Response from University College London Hospitals
    Page 6 · response
    Published 19 December 2023

    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

    Establish mortality surveillance reviews for all UCLH patients with a learning disability who die.

    Verbatim wording from the response

    “In January 2023 we instigated a process as part of our mortality surveillance group to review all patients with a learning disability who die at UCLH. This group is chaired by the corporate medical director and attended by multi-professional group including the learning disability team, quality & safety team and structured judgement review leads.”

    Source location

    Response from University College London Hospitals
    Page 6 · response
    Published 19 December 2023

    Open published response

  3. North Wales (East and Central)

    AI-generated summary

    Hazel Pearson · 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

    Hazel Pearson, who had known coeliac disease, consumed Weetabix in hospital on 26 November 2021, then vomited, aspirated and developed respiratory deterioration before dying from aspiration pneumonia on 30 November 2021. The report raised concerns about inadequate management of food intolerances and allergies, the lack of investigation into the incident, and failures to complete incident reports for other instances of gluten ingestion.

    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 patient safety incidents through adequate governance processes

    Wider context from the report

    “2. The Health Board has not investigated the incident at all. A Medical Examiner Report was prepared following the death in November 2021 highlighting the ingestion of gluten in a coeliac patient. I have raised and continue to raise a number of concerns around the inadequacy of governance and poor investigation processes. ”

    Source location

    Hazel Pearson · 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 revise the governance escalation structure to ensure timely escalation from incident review meetings to the INCHS Group.

    Verbatim wording from the response

    “The documents that underpinned the use of red wrist bands were all agreed and signed off through the relevant governance groups 8-9 months from the task and finish group being established. It is acknowledged that there were gaps in the escalation process from the Make it Safe incident review meetings to the Improving Nutrition, Catering and Hydration Standards (INCHS) Group and the governance structure underneath that group has been reviewed and changes are being made to ensure escalation processes are robust and timely.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 29 November 2023

    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 full Health Board incident-process review through staff co-design.

    Verbatim wording from the response

    “On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 29 November 2023

    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 a new incident reporting and investigation process and procedure, including revised investigation training, for April 2024.

    Verbatim wording from the response

    “On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 29 November 2023

    Open published response

  4. Inner North London

    AI-generated summary

    Glenn Anthony LOCKWOOD · 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

    Glenn Anthony Lockwood, a known drug user receiving opiate replacement treatment, was found unresponsive after a suspected overdose on 14 April 2023 and later suffered a cardiac arrest. Despite hospital treatment, he died on 2 June 2023; the inquest concluded that his death was drug related, with mixed drug toxicity recorded as the medical cause. Concerns included whether Pregabalin abuse risks were sufficiently monitored and whether prescribing and record-keeping issues had been fully investigated and addressed.

    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 Event Analysis failing to fully explore relevant risks

    Wider context from the report

    “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

    Source location

    Glenn Anthony LOCKWOOD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Practice could not arrange a timely SEA because it received no hospital notification or medical cause of death until after the inquest.

    Verbatim wording from the response

    “Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood’s death until a letter dated 30 June 2023 was received from the Senior Coroner’s officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner’s office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner’s investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner.”

    Source location

    Response from The Limehouse Practice
    Page 4 · response
    Published 6 December 2023

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Sasha Honey MISHABI · 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

    Sasha Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to carry out a serious incident investigation when records indicate a relevant pre-admission incident

    Wider context from the report

    “2. SAH Governance, Quality Assurance and Serious Incident processors a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted. b. No serious incident investigation had been carried out by SAH into Mr. Mishabi's death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a statement from ████████ of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023. c. ████████ SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work. ”

    Source location

    Sasha Honey MISHABI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Berkshire

    AI-generated summary

    Francis Osborne Barnes · 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

    Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to investigate deaths and co-operate in joint investigations

    Wider context from the report

    “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death. I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust. The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital. There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed. There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed. There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death. Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored. It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned. Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar). No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed. We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason. The matters of concern can be summarised as follows: 1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector). 2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients. 3. Consideration of how the Oxford Trust responds to and learns from deaths. ”

    Source location

    Francis Osborne Barnes · 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

    Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.

    Verbatim wording from the response

    “3.1 Future Governance of cross-organisational incidents within TVVN”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 3 · response
    Published 6 November 2023

    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

    Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.

    Verbatim wording from the response

    “3.2.8 In response to this inquest several new processes have also been introduced:”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 5 · response
    Published 6 November 2023

    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

    Establish a weekly Patient Safety meeting with the BOB ICB to coordinate multi-organisational incident planning and progress.

    Verbatim wording from the response

    “3.2.8.2 A weekly Patient Safety meeting with Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care Board (ICB) has been established for Patient Safety Teams to plan and liaise on the progress of multi-organisational Patient Safety Incidents. Ad-hoc arrangements can also be made in the event of significant Patient Safety incidents that require urgent planning and response.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 6 · response
    Published 6 November 2023

    Open published response

  7. North West Wales

    AI-generated summary

    Jennifer Lydia Campbell · 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

    Jennifer Lydia Campbell, aged 73, died on 24 February 2022 after an ERCP referral for obstructing gallstones was not received by the endoscopy department. She became severely unwell and died from infection and pneumonia associated with the obstructing gallstones. The principal concerns were the absence of an investigation into the lost referral, lack of learning or audit to prevent recurrence, and continued reliance on paper-based referrals.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clarity about which incidents require investigation

    Wider context from the report

    “a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred. ”

    Source location

    Jennifer Lydia Campbell · 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 formally investigate lost referrals

    Wider context from the report

    “a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred. ”

    Source location

    Jennifer Lydia Campbell · 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 the Health Board incident process through staff co-design.

    Verbatim wording from the response

    “Turning to the first concern, we fully acknowledge that no incident was reported regarding the missing referral form and as such the incident review process did not take place. We are taking steps to ensure staff are aware of the need to report an incident in these situations through awareness and reminders. We are also undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 1 November 2023

    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 a revised incident process and staff training programme, including triangulation of information from all sources, by April 2024.

    Verbatim wording from the response

    “Turning to the first concern, we fully acknowledge that no incident was reported regarding the missing referral form and as such the incident review process did not take place. We are taking steps to ensure staff are aware of the need to report an incident in these situations through awareness and reminders. We are also undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 1 November 2023

    Open published response

  8. County Durham and Darlington

    AI-generated summary

    Sarah Elizabeth Holmes · 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

    Sarah Elizabeth Holmes, who had a history of mental health difficulties and self-harm, was found dead after discharge home following a mental health assessment; the medical cause of death was recorded as asphyxia. The principal concern was the substantial delay in the Trust’s serious incident investigation, which remained incomplete more than a year after her death and was described as neither timely nor responsive. The report also raised concern that such delays could allow lethal hazards to persist and compromise investigations intended to prevent similar deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete serious incident investigations in a timely and responsive way

    Wider context from the report

    “(1) The serious incident investigation by the Trust has been substantially delayed. Sarah died on the 10th of July 2022 and the Trust confirmed to the Coroner’s service that there was to be a serious incident investigation on the 26th July 2022. The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months and on the 13th of March 2023 as this remained the position I listed this case for inquest on the 24th April 2023. On the 17th April 2023 I was alerted by deceased’s family to possible progress in respect of the serious incident investigation in this case, subsequent to their formal complaint to the Trust. After making enquiries of the Trust I was informed that the report would be available at the end of May 2023 and I therefore acceded to a family request to adjourn the final hearing given the short delay this would cause. On the 25th of April 2023 the Coronial service was informed that in fact that it was unlikely that the report would be finalised by May and would be ‘likely end of July/August time’. On the 26th of June I was informed that the report would now not be available until the ‘end of September/beginning of October’ and that the initial dates given were “too ambitious”. The case was listed to commence on the 16th of November 2023 on that basis. On the 28th of July the deceased’s family notified me of a likely further delay in the report being available due to the author’s sick leave from work. The Trust offered reassurance that the report remained due ‘end of September/beginning of October’. On the 28th of September a Pre Inquest Review Hearing was held in relation to a separate discrete issue and I was informed that the report was to be further delayed and would not be available until the end of October. (2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again. (3) If the final version report is received by the end of October it will be some 15 months since Sarah’s death and some 13 months outside the NHS framework. This is neither timely nor responsive. (4) I have previously issued a PFD report in relation to this issue as has the Senior Coroner for Durham and Darlington, Mr Chipperfield, who stated that Tees Esk and Wear Valleys NHS Foundation Trust routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths. (5) I am concerned that these dangers persist, despite the Trust’s response to previous PFD reports and their assurances that remedial action was being taken to eradicate the delays, and as a result it is my statutory duty to make this further report. ”

    Source location

    Sarah Elizabeth Holmes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Central and South East Kent

    AI-generated summary

    Kimberley Sampson and Samantha Mulcahy · 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

    Kimberley Sampson and Samantha Mulcahy died after developing disseminated herpes simplex infections acquired before or around delivery, with both progressing to multi-organ failure despite intensive treatment. The principal concerns were delays in recognising a viral cause and commencing antiviral therapy, alongside a lack of national guidance on antiviral treatment for women presenting with systemic infection in the postpartum or peripartum period. The investigation also found uncertainty about testing staff who had treated both women and was unable to establish whether they had a common source of infection.

    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

    Unclear advice on testing staff during infection investigations

    Wider context from the report

    “(1) The inquest heard evidence of steps having been taken to try to establish if the deaths of both women were linked and if there was a common source of infection. In both inquests the women had been treated in separate hospitals but within the same Trust and two members of staff had been involved in treating both women. The inquest heard that Public Health England were involved in the investigation following the deaths and advice on testing staff was unclear which meant neither of the members of staff involved with both women were tested. The inquest was however unable to establish if the strain of the virus was the same in both women as the evidence on this was inconsistent and on balance the evidence did not support a conclusion that both women were infected by the same source. ”

    Source location

    Kimberley Sampson and Samantha Mulcahy · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. North Wales (East and Central)

    AI-generated summary

    Richard Geraint Griffiths · 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

    Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of investigations to address how transfer of care did not occur

    Wider context from the report

    “a. The Investigation undertaken by the Health Board was deficient in that it did not contain pertinent points relating to how the transfer of care did not occur. I have previously issued a number of Prevention of Future Death Reports relating to quality and timeliness of investigation. ”

    Source location

    Richard Geraint Griffiths · 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 the addendum investigation and progress its report through Health Board approval.

    Verbatim wording from the response

    “████████, the Director of MH&LD Division, reported to you on the 14th September 2023 that an addendum investigation would be undertaken to expand on the pertinent points relating to how the transfer of care of Mr Griffiths did not happen.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 18 September 2023

    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

    Share the addendum investigation report when completed.

    Verbatim wording from the response

    “The investigation is underway, and the investigating officer (IO) has undertaken interviews with staff directly and indirectly involved in Mr Griffiths’ care and treatment. The IO has considered the transfer process that was in place at the time Mr Griffiths was receiving care, the improvements that have been made since, and the review of the Transfer and Discharge of Care Protocol. The addendum report is currently progressing through the Health Board’s approval process and I will be happy to share this with you on its completion in the coming weeks.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 18 September 2023

    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 investigating officers to meet involved staff and share investigation outcomes with them.

    Verbatim wording from the response

    “On the 15th September 2023, the Quality Governance team contacted the Heads of Operations and Heads of Nursing throughout MH&LD to share the concerns you raised about the quality of the investigation report. The Quality Governance team requested that in future, IOs meet with the staff involved in the delivery of care and treatment to explore in detail the decision-making and actions taken when delivering care and that the”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 18 September 2023

    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

    Check during report quality assurance whether investigating officers have explored staff decision-making and actions.

    Verbatim wording from the response

    “outcome of reports are shared with the staff involved. The Quality Governance team now also check for this aspect during the quality assurance of reports. This will ensure more detailed investigations that get to heart of the contributory factors and the root causes of incidents.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 18 September 2023

    Open published response
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Data last updated 7 September 2026