Recurring concern

Failure to learn from deaths through systematic review

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First reported 2 Jul 2014•Latest report 20 May 2026

Definition

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.

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
63

Distinct published reports

Individual concerns
68

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
139

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 Care11
Care Quality Commission8
NHS England8
Nottinghamshire Healthcare NHS Foundation Trust4
Greater Manchester Mental Health NHS Foundation Trust3
HM Prison and Probation Service3
Ministry of Justice3
Pennine Care NHS Foundation Trust3
Priory Group3
College of Policing2
Greater Manchester Police2
Lowdham Grange Prison2
Metropolitan Police Service2
NHS Greater Manchester Integrated Care Board2
North Cumbria Integrated Care NHS Foundation Trust2

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. Inner South London

    AI-generated summary

    Viktoria Was · 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

    Viktoria Was died on 6 January 2013, aged 13, after being injured in a road traffic collision while travelling as a rear-seat passenger in a Volkswagen Polo. The concerns included insufficient regard for injured third parties at the scene, inadequate evidence that lessons had been learned from police pursuits, and insufficient refresher training for police officers.

    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

    Insufficient learning from police pursuit deaths

    Wider context from the report

    “(2) Evidence was placed before me from other unrelated deaths in police pursuits. There was an insufficiency of material to satisfactorily conclude that lessons had been learnt about police pursuits. ”

    Source location

    Viktoria Was · Prevention of Future Deaths report
    Page 1 · 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

    There is solid quantitative and qualitative evidence that lessons from Safer Driving 3 improved management of vehicle pursuits.

    Verbatim wording from the response

    “However, according to ████████ Crime Intelligence Analyst with the Directorate of Professional Standards Specialist Investigations Unit, the quantitative evidence that is available, albeit on a very small numerical base, does indeed show a welcome downward trend:”

    Source location

    2015-0271-Response-by-Metropolitan-Police
    Page 14 · response
    Published 13 July 2015

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    David Peter Greenfield · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

    “1. Not everyone involved in his care was experienced in dealing with patients who had both drug and alcohol problems and the risks of respiratory depression in patients such as the deceased were not fully appreciated. The internal enquiry undertaken by The Priory following the deceased’s death took into account experience and opinions of people within the organisation but did not draw upon research undertaken outside the organisation on the question of sudden and unexpected deaths of people taking prescribed methadone. A re-training programme had been introduced by The Priory following this death but it would seem that there remains a lack of a detailed appreciation of the risks involved of death of patients in receipt of methadone and of patients with the particular characteristics of the deceased and therefore until that understanding and appreciation of risk has been determined training which has already being investigated cannot properly deal with issues which have yet to be identified. It is therefore believed that a further review of such risk and risk management policies needs to be considered with suitable re-training introduced thereafter. ”

    Source location

    David Peter Greenfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. North West Wales

    AI-generated summary

    Mr Hywel Llewelyn Hughes · 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

    Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.

    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 review restraint-related deaths for licensing and responsibility lessons

    Wider context from the report

    “(5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be learnt in so far as their licensing or other responsibilities are concerned. ”

    Source location

    Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026