Recurring concern

Failure to retain safety-critical source records and evidence

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First reported 21 May 2014•Latest report 20 May 2026

Definition

What this concern includes

Includes failures to retain, preserve or protect original or contemporaneous records and other safety-critical evidence whose later availability is needed for patient care, safeguarding, formal review, inquest, investigation or organisational learning, including patient or family registration forms, supervision records, engagement notes, primary-source data and material evidence relevant to deaths.

Not included

  • Excludes records that were never created or are merely incomplete, inaccurate or inaccessible when no failure to retain or preserve the source material is identified.
  • Excludes ordinary record-transfer, filing, retrieval or information-sharing failures where the source record was reliably retained and the deficiency arose later.
  • Excludes routine destruction under an adequate and applicable retention schedule where no safety-critical record or evidence is lost.
  • Excludes non-safety-related administrative records and generic document-management failures without a material care, safeguarding, investigation or safety-learning consequence.
Reports
32

Distinct published reports

Individual concerns
36

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
36

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 Care6
NHS England5
HM Prison and Probation Service3
Ministry of Justice3
Blackpool Teaching Hospitals NHS Foundation Trust2
Lowdham Grange Prison2
Royal College of Pathologists2
Surrey and Borders Partnership NHS Foundation Trust2
Bedfordshire Police1
British Retail Consortium1
Cambridgeshire Constabulary1
Care Quality Commission1
Carillion (AMBS) Limited1
Change, Grow, Live1
Chelsea and Westminster Hospital1

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. Blackpool and the Fylde

    AI-generated summary

    James David FLETCHER · 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

    James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

    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

    Loss or inaccessibility of records material to ongoing patient care

    Wider context from the report

    “2) There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records. Whilst it is understood that “NEWS 2” is being introduced and supersedes the early warning score system being used at the time of the Deceased’s death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report: a) I am concerned that the evidence revealed that substantial periods of time elapsed, at times measuring 9 or more hours, when no entry was made in the Deceased’s History Sheet, notwithstanding the deteriorating nature of the Deceased’s condition. This approach to record keeping carries the risk of material information concerning the condition and care of patients not being communicated between medical, nursing and other clinicians; b) Complete records were not provided to the Court in accordance with directions given prior to the inquest. It was understood from the Trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously. I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible. c) I am concerned that, without records of appropriate quality being made and retained, the opportunity to learn lessons through the process of internal investigations and, should it arise, the Coroner investigation and inquest process will be compromised. ”

    Source location

    James David FLETCHER · 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

    Develop a revised Electronic Document Management System business case for Executive Director consideration.

    Verbatim wording from the response

    “2) Concern regarding record keeping – Whilst the Trust has made progress with electronic access to general practice records and partial provision of electronic records within the Emergency Department we have not as yet implemented an Electronic Document Management System (EDMS). A business case was approved by the Trust Board in January 2018 but because of more pressing cost pressures it has not been possible to progress this to date. A revised business case is in development and due for consideration by Executive Directors by the end of this month.”

    Source location

    2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust
    Page 1 · response
    Published 29 July 2019

    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

    Cost pressures have prevented implementation of the Electronic Document Management System, although a revised business case is being developed.

    Verbatim wording from the response

    “2) Concern regarding record keeping – Whilst the Trust has made progress with electronic access to general practice records and partial provision of electronic records within the Emergency Department we have not as yet implemented an Electronic Document Management System (EDMS). A business case was approved by the Trust Board in January 2018 but because of more pressing cost pressures it has not been possible to progress this to date. A revised business case is in development and due for consideration by Executive Directors by the end of this month.”

    Source location

    2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust
    Page 1 · response
    Published 29 July 2019

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Tina Tait · 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

    Tina Tait underwent elective ovarian cystectomy surgery on 8 May 2018 and subsequently experienced complications, including a colon perforation and later deterioration. She became unresponsive and died on 16 June 2018. The principal concern was the quality, legibility, accessibility and retention of clinical records, which delayed and compromised internal death reviews and could affect continuity of care and the learning of lessons.

    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 retain and make clinical records available

    Wider context from the report

    “I bear in mind that the quality of record keeping is an issue I have raised with the hospital trust previously. In October 2017 I sent to the Trust a letter of concern written in accordance with paragraph 37 of the Chief Coroner’s Guidance No. 5 (Reports to prevent future deaths). That letter was in relation to investigations conducted at this court into the deaths of WB and NM. The letter was felt to be necessary after the inquest into WB’s death had to be conducted in the absence of documentation which the Trust was unable to locate. In May 2017 this court received from the Trust a Sudden Untoward Incident Review into the death of NM which had been completed in the absence of some of the hospital records which could not be located. I was concerned that an improvement in relation to record keeping was essential because having access to quality documentation minimises the chance of, for example, an untoward clinical incident review being delayed or remaining incomplete; it avoids the risk that a coroner’s inquest is delayed. Also, and importantly in my view, it is obviously important that records are readily available to assist a coronial inquiry or indeed an internal hospital review not least in order to ensure any lessons which need to be learnt can be learnt and for this to be achieved as effectively as possible an accurate record of events should be available. In addition to the quality of some of the records relating to Mrs Tait’s care in hospital, the Trust’s internal review was delayed because the clinical records could not be located for some time resulting in a delay before witness statements could be compiled and the Sudden Untoward Incident Review completed the impact of which was the inquest had to be vacated from the original court slot allocated to it and re-listed. Other investigations have been affected by similar issues: a further investigation into the death of JS ultimately proceeded in the absence of hospital records which reportedly went missing after the death and could not be found. In deciding to write this letter I take into account that in response to my letter in October 2017 [see above] I received a response from the Trust dated 4th December 2017 which explained that the point was made that “it is worth noting that the Trust has somewhere in excess of 500,000 sets of patient records and that non-availability is a rare event”. The letter went on to helpfully explain that the Executive Directors had approved a business case for the introduction of an electronic document management system which would mean paper records would be immediately accessible to attending clinicians. Unfortunately, having monitored the situation since then I remain concerned that the Trust’s procedures in terms of accessibility but also to quality of clinical records pose a risk of future deaths if those procedures are jeopardising the likelihood of the correct lessons arising from a death investigation being learnt. ”

    Source location

    Tina Tait · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Liverpool and the Wirral

    AI-generated summary

    Michal Piotr Netyks · 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

    Michal Piotr Netyks, a Polish national serving a custodial sentence at HMP Altcourse, died after jumping head first from first-floor railings on 7 December 2017, the day he was due to be released but was instead detained under immigration powers. The report identifies concerns about the timing and explanation of the immigration detention paperwork, access to legal advice and support, the prison railings, and aspects of the Home Office’s handling of the case.

    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

    Deletion of immigration-detention records to prevent accurate death-in-detention statistics

    Wider context from the report

    “E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018. The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts... “Hi, Name: Michal Netyks DOB: 10 Aug 1982 Nationality: POL Gender: M System: CID Notes Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17. This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████ Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE Death in Custody case update: Inquest to be listed” ”

    Source location

    Michal Piotr Netyks · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Coventry

    AI-generated summary

    Vanessa Ferkova and Sylvia Daniel · 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

    Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

    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

    Destruction of handwritten patient or family registration forms instead of retaining them in the medical record

    Wider context from the report

    “3. Related to this, I am also concerned that an important part of the medical records (the handwritten form completed by patients/families on registration) is destroyed, rather than added to the notes. The fact that information provided directly by patients/families is not available to clinicians is one issue that arises, another is that review of incidents, such as Mrs Daniel’s death is hampered where ‘primary evidence’ is unavailable. ”

    Source location

    Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Lindsey Theresa Hassall · 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

    Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.

    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 retain contemporaneous engagement notes

    Wider context from the report

    “• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) ”

    Source location

    Lindsey Theresa Hassall · 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 concerns about Lifeline/CGL’s records are not a Pennine Care issue, so no further action will be taken.

    Verbatim wording from the response

    “Lifeline, now known as CGL, had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input onto the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager.”

    Source location

    2017-0429-Responses
    Page 2 · response
    Published 27 February 2018

    Open published response

  6. Central Hampshire

    AI-generated summary

    Sean Patrick Plumstead · 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

    Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.

    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 retain important documents or electronic material with specific prisoner records

    Wider context from the report

    “(3) This is not the first death in custody at Winchester Prison where potentially important documents or electronic material has been mislaid or not found because they have not been retained with specific prisoner records. There is therefore a risk that future deaths at the prison occur when such omissions are repeated. ”

    Source location

    Sean Patrick Plumstead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Cambridgeshire and Peterborough

    AI-generated summary

    RICHARD THOMAS DAVIES · 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 Thomas Davies was killed by a police firearms officer during an incident on 21 October 2015 after he threatened his children and fired a homemade firearm at armed police officers. The report raised concerns about the use of unbonded ammunition by the joint Bedfordshire, Cambridgeshire and Hertfordshire Armed Policing Unit, including the absence of safeguards against excessive injury from bullet fragmentation and inadequate records of ammunition decisions.

    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 retain proper records of decisions on operational ammunition

    Wider context from the report

    “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces: • Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations. • Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies. • Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance. ”

    Source location

    RICHARD THOMAS DAVIES · 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 national firearms circulars at quarterly Firearms Steering Group meetings, record discussions and decisions, and update the STRA action log where necessary.

    Verbatim wording from the response

    “38. The STRA also includes an “action log” which is reviewed every three months at the FSG. If there are actions to be taken in response to a new circular, these will be discussed at the FSG and the STRA action log updated accordingly.”

    Source location

    2017-0325-Response-by-Bedfordshire-Police
    Page 7 · response
    Published 3 December 2017

    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

    Record ammunition-selection decisions and relevant circulars and correspondence in a central STRA electronic record.

    Verbatim wording from the response

    “39. As a result of the inquest, an additional provision has been added to the BCH STRA (Appendix 10) to provide a central location for recording any decisions regarding the choice of ammunition and documents relevant to those decisions, including ACPO/NPCC circulars and any correspondence with CAST. The procedures outlined in this response (in particular paragraphs 24, 25, 32 to 34 and 38) are summarised in Appendix 10, a copy of which can be provided to the Coroner if required.”

    Source location

    2017-0325-Response-by-Bedfordshire-Police
    Page 7 · response
    Published 3 December 2017

    Open published response

  8. Wiltshire and Swindon

    AI-generated summary

    Doreen Helen MILLER · 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

    Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

    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 the healthcare-record archiving system to retain and provide records

    Wider context from the report

    “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made. I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken. ”

    Source location

    Doreen Helen MILLER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Manchester South

    AI-generated summary

    Ranjan Raman · 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

    The report states that the deceased was admitted to hospital with low sodium levels and high blood pressure, fell three times, and sustained a head injury followed by a fatal bleed. Concerns included insufficient falls-risk assessment, missing or incomplete neurological observation charts, poor communication between medical and nursing staff, destruction of shift hand-over sheets, and inadequate incident-report details.

    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 retain shift hand-over sheets

    Wider context from the report

    “4. The hand-over sheets for each shift were being shredded by the nurses as soon as the shift was completed. Whilst it is appreciated that these cannot be placed on the record of an individual patient for reasons of confidentiality, there is no reason why they could not be filed on the wards and retained for say 14 days which would allow further reference to be made to them, should this be deemed necessary or helpful. ”

    Source location

    Ranjan Raman · 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

    Consider introducing electronic archiving of ward and departmental handover sheets.

    Verbatim wording from the response

    “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

    Source location

    R-Mistry-Response
    Page 3 · response
    Published 4 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Paper handover sheets are not archived because confidentiality and maintaining reliance on the current sheet create practical constraints, although electronic archiving may be introduced.

    Verbatim wording from the response

    “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

    Source location

    R-Mistry-Response
    Page 3 · response
    Published 4 March 2016

    Open published response

  10. Surrey

    AI-generated summary

    Adam James Withers · 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

    Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

    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 clear guidance on preserving original records after a patient’s death

    Wider context from the report

    “At the inquest an issue arose as to when the manuscript observation record for Adam Withers for the 9th May 2014 was completed and I asked to see the original document. I was provided with a witness statement from the Trust’s Medical Records Manager indicating that, after Adam Withers’ death, the original record had been scanned in to his electronic records and then destroyed. The Trust considers that this is permitted by the NHS Code of Practice on Record Management. It is not clear to me whether that is a correct analysis of the Code or not. No clear guidance appears to exist. Whilst I understand that paper records may now routinely be scanned in to a patient’s electronic record and then destroyed, my concern relates to that taking place after a patient has died and it is apparent that the death must be reported to the police and/or coroner. The destruction of any original document which is still in existence at the time of death could undermine the efficacy of the police investigation and/or the coroner’s investigation. In turn, this could adversely affect the coroner’s ability to establish the facts of how the deceased person came by his death and to report concerns for the prevention of future deaths. ”

    Source location

    Adam James Withers · Prevention of Future Deaths report
    Page 4 · 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

    Add clear guidance on retaining original paper records after a potentially reportable death to the revised NHS Records Management Code before publication.

    Verbatim wording from the response

    “The NHS Records Management Code of Practice is currently under review and a revised Code is due to be published when the review is complete. Clear guidance on the point you raise will be added to the revised Code before publication.”

    Source location

    2016-0059-Response-by-Department-of-Health
    Page 2 · response
    Published 15 February 2016

    Open published response
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Data last updated 7 September 2026