Recurring concern

Unreliable internal disciplinary proceedings

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First reported 17 Dec 2018•Latest report 25 Oct 2024

Definition

What this concern includes

Includes failures in internal disciplinary proceedings that delay or prevent timely progression to hearing and conclusion, including investigation of allegations, witness interviews, case management, scheduling, resource or responsibility arrangements and proactive escalation of long-outstanding cases.

Not included

Excludes clinical care, patient-safety incident investigations and external regulatory investigations unless the assertion specifically concerns an internal disciplinary proceeding.
Excludes generic employee-support, wellbeing or occupational-health deficiencies where the disciplinary process itself is not deficient.
Excludes substantive disagreement with a disciplinary outcome where the proceeding was timely and reliably managed.
Excludes ordinary employment administration unrelated to progressing or concluding an internal disciplinary proceeding.

Reports: 2
Individual concerns: 2
Date range: 2018–2024
Stated actions: 8

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.

Independent Office for Police Conduct1

North London NHS Foundation Trust1

West Yorkshire Police1

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.

25 Oct2024
West Yorkshire Eastern
Concerns raised1
1. Delays in concluding internal disciplinary proceedings
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
  Review gross-misconduct investigations quarterly to assess whether they have sufficient resources.
  Stated by West Yorkshire PoliceStated completed
2. Action
  Review gross-misconduct investigations annually to ensure they are conducted promptly and have sufficient resources.
  Stated by West Yorkshire PoliceStated completed
3. Action
  Meet quarterly with IOPC senior leaders to review investigation resources and welfare provisions.
  Stated by West Yorkshire PoliceStated completed
AI-generated summary

Martin Ian Stubbs · 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

Martin Ian Stubbs was a serving police officer who was arrested, suspended from duty and remained on bail until his death. He died by suicide by hanging at his home on 26 August 2024. The principal concern was the prolonged delay in concluding the internal disciplinary process, which the family believed contributed to his death and might reflect wider resource or management issues.

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
Delays in concluding internal disciplinary proceedings
Wider context from the report
“Mr Stubbs’ father (a former officer himself and still a civilian police employee) expressed his firm belief that the length of time he had been suspended from duty had played a significant part in his son’s decision to take his life. It is a concern that someone subject to an internal disciplinary process has a legitimate expectation that that process will be dealt with expeditiously in the interests of all parties, and that legitimate expectation was not met in Mr Stubbs’ case. Mr Stubbs’ family do not understand whether the delay in concluding the process reflects resource issues or an institutionalised practice of allowing such matters to drift without proactive management to bring them to a conclusion. Anecdotally, Mr Stubbs’ family are aware of other long outstanding internal disciplinary proceedings and fear other families may have to go through an experience similar to theirs. ”
Source location
Martin Ian Stubbs · 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
Review gross-misconduct investigations quarterly to assess whether they have sufficient resources.

Verbatim wording from the response
“Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:”

Source location
Response from West Yorkshire Police
Page 3 · response
Published 30 October 2024
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 gross-misconduct investigations annually to ensure they are conducted promptly and have sufficient resources.

Verbatim wording from the response
“Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:”

Source location
Response from West Yorkshire Police
Page 3 · response
Published 30 October 2024
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
Meet quarterly with IOPC senior leaders to review investigation resources and welfare provisions.

Verbatim wording from the response
“Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:”

Source location
Response from West Yorkshire Police
Page 3 · response
Published 30 October 2024
Open published response
17 Dec2018
Inner North London
Concerns raised1
1. Delays in interviewing witnesses to progress disciplinary hearings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Roll out Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.
  Stated by North London NHS Foundation TrustStated in progress
2. Action
  Review the disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.
  Stated by North London NHS Foundation TrustStated in progress
3. Action
  Require a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.
  Stated by North London NHS Foundation TrustStated completed
1. Action
  Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.
  Stated by North London NHS Foundation TrustStated planned
2. Action
  Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Agnes Stephanie LAMBERT · 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

Agnes Stephanie Lambert was a mental health nurse who died after an investigation into allegations concerning her contact with a patient who was fixated on her. The inquest determined that her death was suicide, with the medical cause recorded as suspension by ligature. Concerns included the failure to move her to another ward despite recognising the patient’s fixation, and an allegedly unacceptable delay in progressing the disciplinary 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
Delays in interviewing witnesses to progress disciplinary hearings
Wider context from the report
“2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing. This was a distressing time for Ms Lambert and she finally went on sick leave. The service manager who gave evidence in court agreed that this was an unacceptable delay. ”
Source location
Agnes Stephanie LAMBERT · 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
Roll out Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.

Verbatim wording from the response
“To support this, we are in the process of rolling out ‘vital conversations’ training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised.”

Source location
2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018
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 disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.

Verbatim wording from the response
“We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

Source location
2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018
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 a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.

Verbatim wording from the response
“We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

Source location
2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018
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
Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.

Verbatim wording from the response
“Vital Conversations training, will facilitate more issues being resolved informally through the supervision process. For those investigations that do proceed formally, there will be a greater focus on managers’ responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme. The refreshed policy is expected to complete in March 2019.”

Source location
2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 3 · response
Published 17 December 2018
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
Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.

Verbatim wording from the response
“The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made.”

Source location
2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 3 · response
Published 17 December 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in concluding internal disciplinary proceedings

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

Concerns raised1

Delays in interviewing witnesses to progress disciplinary hearings

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.5

Actions described in response 3

Actions described in response 5