Recurring concern

Failure to learn from deaths through systematic review

First to latest report 2 Jul 2014 — 20 May 2026

Reports that mention this concern
63
Times this concern has been raised
68
Stated actions linked to this concern
139

What this concern includes

Includes failures to review, investigate, reflect on or derive and communicate safety lessons from deaths, including the anchor's failure to review restraint-related deaths for licensing and responsibility lessons and failures to reflect on or learn from deaths in other services or settings.

What is not included
  • Excludes deficiencies in the underlying care, restraint, licensing or operational process where no failure of post-death review or learning is identified.
  • Excludes general incident-investigation deficiencies that concern events other than deaths unless the assertion explicitly connects them to learning from deaths.
  • Excludes failures to implement a clearly identified safety action after lessons have already been established, where the concern is implementation rather than death review or learning.
  • Excludes coroner, inquest or regulatory disclosure failures where the unsafe condition is incomplete or late disclosure rather than failure to review deaths for safety learning.

Reports and published responses 63 reports

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

  1. Manchester North

    AI-generated summary

    Anugrah Abraham (“Anu”) · 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

    Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.

    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 learn from deaths and reflect on occupational health care processes

    Wider context from the report

    “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP. Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures. It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not addressed. ”

    Source location

    Anugrah Abraham (“Anu”) · 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

    Embed recording of suicidal-ideation frequency and informal team risk advice in the Assessment of Suicide and Self Harm protocol.

    Verbatim wording from the response

    “2. An informal post-incident briefing was held with relevant members of the OH team at the time. It should be noted that the OHU did not undertake formal serious incident analysis (SIA) until after the inquest on the guidance of the IOPC. The learning that was identified in the SIA related to the addition of recording frequency of suicidal ideation, and the recording of informal team advice/conversations. As a consequence, the Assessment of Suicide and Self Harm protocol was updated to include this learning, and it is now embedded into normal practice. There has also been the introduction of a recorded message informing callers where to obtain crisis support on initial telephone contact with the OH team.”

    Source location

    Response from West Yorkshire Police
    Page 2 · response
    Published 15 January 2025

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    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 national oversight, governance and assurance of organisational learning from force activity.

    Verbatim wording from the response

    “The Director of the National Police Wellbeing Service provided evidence at the inquest and as the Co-Chair of the NPCC Health & Safety Wellbeing Board initiated a review into national oversight, governance, and assurance. In addition to this, the Board has communicated the areas of concern to all forces so as raise their awareness of the organisational learning outcomes and how these are best adopted and applied within forces.”

    Source location

    Response from College of Policing and National Police Chiefs' Council
    Page 4 · response
    Published 15 January 2025

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    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

    Communicate organisational-learning concerns and outcomes to all forces and continue monitoring implementation of recommendations.

    Verbatim wording from the response

    “The Director of the National Police Wellbeing Service provided evidence at the inquest and as the Co-Chair of the NPCC Health & Safety Wellbeing Board initiated a review into national oversight, governance, and assurance. In addition to this, the Board has communicated the areas of concern to all forces so as raise their awareness of the organisational learning outcomes and how these are best adopted and applied within forces.”

    Source location

    Response from College of Policing and National Police Chiefs' Council
    Page 4 · response
    Published 15 January 2025

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Aarav Pal CHOPRA · 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

    Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to learn from deaths at the earliest opportunity

    Wider context from the report

    “5. Learning from deaths: The initial M&M meeting after Aarav's death was described as inadequate. My concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. ”

    Source location

    Aarav Pal CHOPRA · 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 Trust-wide M&M process, develop terms of reference, consult clinical leads and obtain external review support to identify improvements.

    Verbatim wording from the response

    “The Trust’s entire M&M process is currently under review. Terms of reference are being developed, and support has been requested from the lead at GOSH to assist with the reviews. Meetings with the Clinical Service and Governance Leads are in place over the coming weeks with 4 main specialities at the Trust’s Children’s site to review the current practice and identify areas for development. We expect this work to be complete by May 2025.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 13 January 2025

    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

    Operate weekly PSIRF Decision Team meetings to select learning methodologies for relevant incidents and deaths.

    Verbatim wording from the response

    “A weekly PSIRF Decision Team meeting was set up on 29 April 2024 and is chaired either by the Chief Medical Officer or Chief Nursing and Midwifery Officer. In attendance at these meetings are appropriate representatives from all Divisions within the Trust, who present specific incident categories and deaths where there might be questions raised about the care provided, identified through incident reporting structures and complaints.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 13 January 2025

    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 and amend Interventional Radiology governance practice to achieve learning at the earliest opportunity.

    Verbatim wording from the response

    “In addition, governance practice within the Interventional Radiology Department is under review and will be amended to ensure that learning is achieved at the earliest opportunity.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 13 January 2025

    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

    Disseminate haemothorax management learning through trauma scenario training and a one-page incident summary.

    Verbatim wording from the response

    “Recommendation 9 (LP8) - Disseminate learning about management of haemothorax from this case in trauma scenario training and by distribution of a 1-page summary of the incident and the learning points identified. In progress”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 5 · response
    Published 13 January 2025

    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

    Birmingham Women’s and Children’s NHS Foundation Trust will address concerns about the inadequate mortality and morbidity meeting in its own response.

    Verbatim wording from the response

    “5. Learning from deaths”

    Source location

    Response from DHSC
    Page 3 · response
    Published 13 January 2025

    Open published response

  3. Cheshire

    AI-generated summary

    Victor William Knowles · 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

    Victor William Knowles was admitted to a nursing home for short-term care planning while at high risk of dehydration and malnutrition. He lost 5kg, had very low fluid intake, and later required hospital treatment for severe dehydration and malnutrition, acute kidney injury, hypernatremia and osmotic demyelination syndrome before dying on 20 January 2024. Concerns included inaccurate or incomplete information being shared with healthcare professionals, failures to obtain timely medical treatment, and limited investigation, reflection and learning from his care and 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

    Lack of a mechanism for learning from deaths during or following Nursing Home admission

    Wider context from the report

    “4. The evidence highlighted that there was no mechanism for lessons to be learned from deaths which occur during or following admission to the Nursing Home. ”

    Source location

    Victor William Knowles · 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

    Existing investigation and learning arrangements are appropriate; no further changes are required beyond measures already discussed at the inquest.

    Verbatim wording from the response

    “The Home has at all times had in place a comprehensive policy for undertaking internal investigations including guidance on when these are required. As you will appreciate, given the setting in which the Home operates, it would not be reasonably practicable nor proportionate to commence an investigation following all deaths or admissions to hospital. Rather, this requires the review of all incidents whereby a sudden death occurs or any unexpected hospital admission. Furthermore, a monthly review of deaths and hospital admissions considers any themes or trends. This is consistent with the protocols observed by care homes throughout the industry. We are also obliged to notify the Care Quality Commission of deaths in our home without delay under our provider and manager registration.”

    Source location

    Response from Springcare Care Homes Ltd
    Page 1 · response
    Published 9 January 2025

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Michael John THOMPSON · 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

    Michael John THOMPSON underwent hindquarter amputation for chondrosarcoma and later collapsed after vomiting; post-mortem examination found an internal hernia through a peritoneal defect, leading to aspiration. Concerns were raised that the peritoneal defect and repair were not recorded in the operation note, and that the Trust’s investigation did not address this issue or adequately support 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 learn from deaths

    Wider context from the report

    “2. Under the PSIRF process a PSII investigation was undertaken however this only dealt with resuscitation efforts and did not address the peritoneal defect and its repair which was the root cause of Mr Thompson’s death. This raises a concern about the adequacy of investigations being undertaken by the Trust and their ability to learn from deaths. ”

    Source location

    Michael John THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Derby and Derbyshire

    AI-generated summary

    Alison BINYON · 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

    Alison Binyon, who had a history of mental health difficulties and self-harm involving ligation, was found unresponsive at her residential home on 11 September 2019 and died on 13 September 2019 after developing a hypoxic brain injury. The report identified concerns about communication and uncertainty around her planned move to step-down accommodation, and about the absence of an internal review after her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to conduct internal reviews following deaths

    Wider context from the report

    “The court heard evidence from the Adult Social Care Team that communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team. The court further heard that uncertainty can be a potential stressor or trigger for self-harm for those with a diagnosis of Emotionally Unstable Personality Disorder. There is an inherent uncertainty in the timescales for moving as it depends on the availability of suitable accommodation and the situation therefore requires careful management and communication. Whilst consideration had been given to conversations with the service user in this situation, the court heard evidence from those supporting Alison (including community mental health nurses) that they were unclear on the stage the process had reached, the specific steps of the process and the likely timescales involved. This affected the type of support they could provide. There was a lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community. Further, no internal review was carried out at Leicestershire County Council following Alison's death. If such reviews are not conducted this could lead to inadequate learning from deaths which creates a risk of further deaths. ”

    Source location

    Alison BINYON · 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 and implement a procedure requiring Adult Social Care managers to conduct internal reviews after unexpected deaths and identify learning or required policy changes.

    Verbatim wording from the response

    “Nevertheless, in light of this concern being raised in the RPRD, I have considered this matter and consultation has occurred within the department around the internal review process for when an unexpected death occurs.”

    Source location

    Response from Leicestershire County Council
    Page 3 · response
    Published 11 November 2024

    Open published response

  6. Nottinghamshire

    AI-generated summary

    Mark Stephen Beresford · 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

    Mark Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act with due reflection and candour during inquests

    Wider context from the report

    “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances. The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances. Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner. He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.” When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood. I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken. The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch. Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody. 1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby. 2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody. ”

    Source location

    Mark Stephen Beresford · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure senior staff attending inquests are confident addressing PFD issues and receive legal-representative support when giving evidence.

    Verbatim wording from the response

    “I will further ensure that those senior staff attending inquests to provide the Coroner and jury with information relating to PFDs are confident in dealing with the issues raised, and receive good support from our legal representatives as to what is required when giving evidence.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 31 October 2024

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Joan Margaret KNIGHT · 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

    Joan Margaret Knight underwent treatment for severe coronary artery stenosis, including stent procedures, and developed bleeding, cardiac tamponade and multi-organ failure before dying on 25 May 2024. The report raised concern that the mortality review was completed incorrectly and contained contradictory statements about whether the death was avoidable, potentially limiting learning from cases and creating a risk of future 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

    Inadequate learning from mortality review cases

    Wider context from the report

    “The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths. ”

    Source location

    Joan Margaret KNIGHT · 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

    Share identified learning with Hospital Medical Directors and Directors of Nursing across the Trust’s hospitals.

    Verbatim wording from the response

    “I further note your concern regarding the risk of future deaths, which has been addressed below. The focus of the actions has been at the Queen Elizabeth Hospital Birmingham (QEHB) but the learning identified in this response has been shared with each of the responsible Hospital Medical Directors and Directors of Nursing covering QEHB, Birmingham Heartlands Hospital and Good Hope Hospital respectively for implementation.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 1 · response
    Published 22 October 2024

    Open published response

  8. Cumbria

    AI-generated summary

    Nancy ROGERS · 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

    Nancy ROGERS collapsed on 18 November 2023, attended the emergency department, and was discharged home before being found unresponsive the following morning. The inquest recorded bilateral haemothorax due to a ruptured dissecting aortic aneurysm. Concerns were raised about her discharge after emergency attendance and the reported absence of learning or teaching following a similar death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to undertake learning or teaching following comparable deaths

    Wider context from the report

    “(1) At the inquest into Shirley Potter's death the hospital report indicated no learning was required as her presentation was not typical. The circumstances in both these cases are remarkably similar in that both ladies attended the emergency department at Furness General and were allowed home only to die within a day of the same cause and as far as the attending clinician at today's hearing knew no learning or teaching has taken place since Nancy's death. ”

    Source location

    Nancy ROGERS · 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

    Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.

    Verbatim wording from the response

    “A meeting was held between the Clinical Lead - Emergency Medicine (FGH), the Clinical Lead - Emergency Medicine (RLI), the Clinical Lead - Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the causes of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at the meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place:”

    Source location

    Response from Morecambe Bay NHSFT
    Page 1 · response
    Published 30 July 2024

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    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

    Display an aortic dissection poster with a linked educational video in emergency department clinical and triage areas.

    Verbatim wording from the response

    “• An A4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference. The QR code links to a video on the Aortic Dissection Charitable Trust's website.”

    Source location

    Response from Morecambe Bay NHSFT
    Page 1 · response
    Published 30 July 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

    Disseminate the aortic dissection video to medical and nursing staff across emergency, urgent treatment, same-day emergency care and acute medical units, tracking viewings and adding new starters.

    Verbatim wording from the response

    “• The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust’s main hospitals, between July and the end of September. A list of the”

    Source location

    Response from Morecambe Bay NHSFT
    Page 1 · response
    Published 30 July 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

    Include aortic dissection in the August induction programme for new doctors.

    Verbatim wording from the response

    “• Aortic dissection is now included in the new doctor induction in August.”

    Source location

    Response from Morecambe Bay NHSFT
    Page 2 · response
    Published 30 July 2024

    Open published response

  9. Leicester City and South Leicestershire

    AI-generated summary

    Ash BANNISTER · 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

    Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.

    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

    Investigation process failing to identify all learning from deaths

    Wider context from the report

    “It was accepted by United Children’s Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash’s death. If an investigation was undertaken by United Children’s Services after Ash’s death it: (1) Was not documented; (2) Failed to identify all of the learning uncovered at the inquest; (3) Failed to trigger any changes at United Children’s Services. The investigation process in place at United Children’s Services is therefore not fit for purpose. ”

    Source location

    Ash BANNISTER · 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

    Require an independent third party to conduct investigations under the Death and Serious Incidents Policy.

    Verbatim wording from the response

    “We carried out our internal investigation in accordance with the organisation's Death and Serious Incidents Policy. This sets out the procedure that must be followed in the event of a death or serious incident concerning one of our young people. We initiated the investigation a few weeks after Ash died. A key part of that process is considering lessons that we can learn as an organisation. We regret that we did not document the investigation and our conclusions. The senior management team, who are responsible for such investigations, have been reminded that the full and proper procedure as set out in the Death and Serious Incidents Policy must be followed. We have also made a change to the Policy which now requires that an independent third-party conduct the investigation in line with the procedure set out in the Policy.”

    Source location

    Response from United Childrens Services
    Page 6 · response
    Published 30 April 2024

    Open published response

  10. Nottinghamshire

    AI-generated summary

    Alexander Vitali Lyalyushko · 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

    Alexander Vitali Lyalyushko took his own life by hanging at his home on 2 January 2023, where he lived alone. A request from his GP for mental health service involvement in November 2022 was not actioned, and he was not receiving mental health services at the time of his death. The report also identified deficiencies in the initial review and incident investigation following his death, including failure to identify the unactioned request and failure to consult his family.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to identify un-actioned service-involvement requests in post-death incident reviews

    Wider context from the report

    “1. Inadequate review and incident investigation following a death Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. ”

    Source location

    Alexander Vitali Lyalyushko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient learning and corrective action following deaths

    Wider context from the report

    “1. Inadequate review and incident investigation following a death Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks). I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review. If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances. I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place. ”

    Source location

    Alexander Vitali Lyalyushko · 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 further review and addendum to incorporate newly identified information and issues from the inquest findings.

    Verbatim wording from the response

    “record and therefore unavailable to the author of the CNR. This information became known about in January 2024 and agreed that this would be dealt with via a statement from the relevant team leader. This statement was to confirm that this referral was not available or known to the author of the CNR, confirm what had occurred, confirm what should have happened according to procedure, and what had since been put in place to reduce risk of recurrence.”

    Source location

    Response from Nottinghamshire Healthcare NHS FT
    Page 2 · response
    Published 13 August 2024

    Open published response

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

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Data last updated 7 September 2026