20 May 2026 Isaac Charles ARROWSMITH · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure of internal investigations to identify important issues in care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
East Cheshire NHS Trust
Obtain or access all relevant healthcare records for future patient safety investigations.
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East Cheshire NHS Trust
Introduce a standard MDT review commissioning email template specifying required clinical specialities and professional groups.
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East Cheshire NHS Trust
Develop an MDT review quick-reference guide for consistent patient safety reviews.
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East Cheshire NHS Trust
Update the MDT review report template with prompts covering clinical referral processes and other key enquiry areas.
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East Cheshire NHS Trust
Deliver focused MDT review and After Action Review training through specialty and departmental meetings alongside the established Patient Safety Investigation programme.
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East Cheshire NHS Trust
Embed MDT review training as an ongoing resource and support clinical leaders to cascade learning across clinical teams.
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Isaac Charles ARROWSMITH · 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
Isaac Arrowsmith, aged 19, died on 2 January 2026 after repeated hospital attendances for chest pain, breathing difficulty and coughing blood, followed by deterioration at home and an unsuccessful resuscitation. The report identified concerns about failure to recognise the clot risk associated with haemoglobin Rainier disease, failure to make a virtual ward referral that would have led to hospital admission, and shortcomings in the Trust’s internal investigation and learning processes.
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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 investigations to identify important issues in care
Wider context from the report “1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease.
I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. I heard evidence that these are false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes
The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. I have received a statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis , it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. I am concerned that the investigation process has failed to highlight a very important issue in care , and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost.
My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised.
” Source location Isaac Charles ARROWSMITH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain or access all relevant healthcare records for future patient safety investigations.
Verbatim wording from the response “1. The Trust will obtain and/or gain access to all relevant healthcare records as part of any patient safety investigation to ensure that all relevant information is considered as part of the review” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a standard MDT review commissioning email template specifying required clinical specialities and professional groups.
Verbatim wording from the response “2. The introduction of a standard MDT review commissioning email template which specifies the required clinical specialities and professional groups contributing to each review” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an MDT review quick-reference guide for consistent patient safety reviews.
Verbatim wording from the response “3. Development of an MDT review quick-reference guide to provide staff with clear and consistent guidance on undertaking patient safety MDT reviews, which is due to be completed by 20 July 2026” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the MDT review report template with prompts covering clinical referral processes and other key enquiry areas.
Verbatim wording from the response “4. The MDT review report template is being reviewed and will be updated to include specific prompts relating to the review of clinical referral processes and other key areas of enquiry, which is due to be completed by 20 July 2026” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver focused MDT review and After Action Review training through specialty and departmental meetings alongside the established Patient Safety Investigation programme.
Verbatim wording from the response “5. Delivering focused bitesized MDT review and After Action Review training through specialty and departmental meetings to strengthen staff knowledge and promote a consistent approach to reviews, complemented by the Trust’s dedicated full-day Patient Safety Investigation training programme” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed MDT review training as an ongoing resource and support clinical leaders to cascade learning across clinical teams.
Verbatim wording from the response “6. Embed MDT review training as an ongoing educational resource and support Clinical Leads, Senior Sisters and Matrons to cascade learning throughout clinical teams” Source location Response from East Cheshire NHS Trust
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Concerns raised 1
Failure to disseminate learning and address identified concerns nationally View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.
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Sunny Elise EYMOND · Prevention of Future Deaths report
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Report summary
Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to disseminate learning and address identified concerns nationally
Wider context from the report “1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level .
2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs.
” Source location Sunny Elise EYMOND · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Sunny, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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14 Oct 2025 Mohan Singh Hothi · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to identify, reflect upon, and remediate sub-optimal practice View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Barking, Havering and Redbridge University Hospitals NHS Trust
Review the post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Provide continuing Falls Lead communication and support to identify training needs and implement resulting training across the Geriatrics Care Group.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.
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Mohan Singh Hothi · 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
Mohan Singh Hothi was admitted to hospital after a fall at home and was found to have a catastrophic subdural haematoma; he died later that day. Concerns included the Trust not investigating two serious injuries from previous unwitnessed falls through its Patient Safety Framework, and vague and incomplete evidence about reflection and remediation.
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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, reflect upon, and remediate sub-optimal practice
Wider context from the report “1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice .
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
” Source location Mohan Singh Hothi · Prevention of Future Deaths report
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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 post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.
Verbatim wording from the response “In February 2025, a total of 36 falls were reported, increasing to 45 falls in March 2025, compared with an average of approximately 25 falls per month in the Geriatrics Care Group. In response to this rise in falls and the associated risk of serious patient harm, the Head of Nursing and The Quality and Safety Advisor in Geriatrics implemented an action plan to address and monitor the situation. This action plan included the following measures:” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Verbatim wording from the response “2. Every reported fall incident is discussed at the weekly Geriatrics Care Group incident review meeting, chaired by the Quality and Safety Advisor, to determine preventability, assess any harm sustained and share learning across the Care Group.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Verbatim wording from the response “4. All inpatient falls within the Geriatrics Care Group are reported to the Trust’s Quality Governance and Steering Group (QGSG), with any falls resulting in serious harm detailed. Decisions regarding escalation for a learning response are formally recorded and reported to the Trust Board.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide continuing Falls Lead communication and support to identify training needs and implement resulting training across the Geriatrics Care Group.
Verbatim wording from the response “5. Ongoing communication and support from the Trust Falls Lead is provided to identify training needs which are subsequently implemented across the Care Group.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.
Verbatim wording from the response “Further action to be completed” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Verbatim wording from the response “The investigations conducted under incident reference numbers ████████ concluded that both falls were unpreventable. Mr Hothi was assessed as having full mental capacity, displayed no signs of confusion, and was able to understand and follow instructions. Under these circumstances, patients are not provided with constant supervision, as they are deemed capable of communicating their care needs to the nursing staff. Moreover, continuous supervision would require the implementation of a Deprivation of Liberty Safeguards (DoLS) authorisation, for which Mr Hothi did not meet the criteria.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Verbatim wording from the response “In accordance with the Patient Safety Incident Review Framework (PSIRF) and the Trust PSIRF plan, incidents are referred for a learning response when the contributing factors are not well understood or when there is potential for significant local or organisational learning. Following the review of incidents ████████, it was determined that the underlying factors were clearly understood – specifically that Mr Hothi chose to mobilise independently without awaiting assistance from nursing staff.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Verbatim wording from the response “• The factors contributing to Mr Hothi’s falls were known and understood; therefore, no further investigation was required. Ongoing actions to manage these factors were already in place.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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25 Sep 2025 Zara Alice Cheesman · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of detailed organisational understanding of the extent of identified issues View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Zara Alice Cheesman · 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
Zara Alice Cheesman died in hospital on 23 December 2024 from meningococcal meningoencephalitis after becoming progressively unwell. The report identified concerns about inadequate assessment and non-conveyance by ambulance staff on 21 December, alongside insufficient organisational oversight, audit, monitoring and continuing professional development for assessing seriously ill children.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of detailed organisational understanding of the extent of identified issues
Wider context from the report “1. There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made
2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines
3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person)
I am not reassured that necessary actions to address these serious issues identified are in place.
” Source location Zara Alice Cheesman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand clinical audits to mandate reviews of remote and face-to-face paediatric care episodes against clinical guidelines.
Verbatim wording from the response “We have expanded our clinical audit programme to include mandatory reviews of paediatric care episodes. This ensures that both remote and face-to-face interactions are assessed for adherence to clinical guidelines.
To enhance oversight, we have introduced compliance tracking for clinical bulletins and integrated this into our performance monitoring structures.” Source location Response from East Midlands Ambulance Service
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23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
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Concerns raised 1
Failure of governance processes to reflect upon sub-optimal practice View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Barts Health NHS Trust Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Barts Health NHS Trust
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
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Barts Health NHS Trust
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
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Barts Health NHS Trust
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
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Barts Health NHS Trust
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
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Barts Health NHS Trust
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
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Tony Buengo Jackson · Prevention of Future Deaths report
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Report summary
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of governance processes to reflect upon sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon , and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” Source location Tony Buengo Jackson · Prevention of Future Deaths report
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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 case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Verbatim wording from the response “• The case has been reviewed through the Surgical Division’s Morbidity and Mortality (M&M) process and learning shared.” Source location Response from Barts Health NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Verbatim wording from the response “• All deaths that proceed to Coroner’s inquest are now reviewed at the Patient Safety Event Response Meeting (PSERM) to ensure:
o The event is captured on Datix,” Source location Response from Barts Health NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Verbatim wording from the response “• The Endoscopy Governance Meeting is being expanded to include the surgical directorate as a bi-monthly joint forum agenda (within the Gastroenterology Governance Forum) between Surgery and Gastroenterology, with governance and nursing representation, to support shared learning from endoscopy-related adverse events.” Source location Response from Barts Health NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Verbatim wording from the response “• Governance presence is now embedded within Surgical and Gastroenterology M&M meetings to ensure improved linkage between M&M learning, Datix reporting, and PSIRF oversight.” Source location Response from Barts Health NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Verbatim wording from the response “• The Trust is also strengthening the recording of Morbidity and Mortality (M&M) discussions across all divisions. Following a review of M&M processes at the December Quality and Safety Committee, divisions will be supported to embed improved documentation standards and the use of Microsoft Copilot to capture decisions, themes and actions. This will ensure that learning identified at M&M is consistently recorded, traceable, and easily retrievable for follow-up through PSERM and divisional governance structures.” Source location Response from Barts Health NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Verbatim wording from the response “Regarding the concerns about application of the PSIRF, the Trust is reviewing the mortality and morbidity process across the hospital to ensure better alignment with learning and improvement systems. CQC have raised concerns with the Trust that there is disparity in the effective application of PSIRF across the different hospital’s governance teams. The CQC will review the Trust’s response and decide if any further action is needed.” Source location Response from Department of Health and Social Care
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2 May 2025 Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Flawed investigations failing to identify systemic failures and learning View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
The Children's Trust
Implement a revised incident management policy and process based on national best practice.
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The Children's Trust
Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
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The Children's Trust
Implement the national Patient Safety Incident Response Framework for incident investigations.
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The Children's Trust
Review all incidents through multidisciplinary panels representing the organisation.
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The Children's Trust
Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
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The Children's Trust
Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
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AI-generated summary
Raihana Oluwamidalo Awolaja · 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
Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Flawed investigations failing to identify systemic failures and learning
Wider context from the report “2. That there may be culture of cover up at the TCT, in that they carried out a flawed investigation after this incident , pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths.
” Source location Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a revised incident management policy and process based on national best practice.
Verbatim wording from the response “• Incident Management Policies and Processes: We have developed and implemented a revised incident management policy and process that incorporates national best practice standards to ensure robust and consistent handling of all incidents.” Source location Response from The Children’s Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
Verbatim wording from the response “• Clinical Governance Framework: Significant investment has been made in strengthening our clinical governance framework. This enhancement enables us to better identify and respond to recurring themes and trends, promoting continuous organisational learning and improvement.” Source location Response from The Children’s Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national Patient Safety Incident Response Framework for incident investigations.
Verbatim wording from the response “• PSIRF Implementation: We have fully implemented the national Patient Safety Incident Response Framework (PSIRF) to guide all incident investigations, ensuring a consistent, transparent, and learning-focused approach.” Source location Response from The Children’s Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all incidents through multidisciplinary panels representing the organisation.
Verbatim wording from the response “• Multidisciplinary Panels: All incidents are now reviewed by multidisciplinary panels comprising representatives from across the organisation, facilitating a comprehensive and collaborative review process.” Source location Response from The Children’s Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
Verbatim wording from the response “• Internal Oversight of External Reviews: Investigations commissioned externally are now subject to additional internal oversight through our governance procedures. This internal review ensures that external findings are scrutinised rigorously and challenged appropriately to maintain high standards of accountability.” Source location Response from The Children’s Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
Verbatim wording from the response “• Thematic Reviews: We conduct thematic reviews of all serious incidents to identify recurring issues. The findings from these reviews directly inform staff training and ongoing service improvements.” Source location Response from The Children’s Trust
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Concerns raised 1
Failure to undertake deep-dive safety audits examining patterns and trends View source
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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× 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 deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Source location Christian James Gabriel Hobbs · Prevention of Future Deaths report
Open source report
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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 Work with the Trust to gain assurance that progress is being made on PSIRF quality improvement initiatives.
Verbatim wording from the response “• North West Anglia NHS Foundation Trust’s Quality Assurance Committee holds a monthly meeting, alternating between surveillance and deep dives on identified themes. This is attended by representatives from CPICB. The Trust’s Patient Safety Incident Response Framework (PSIRF) plan outlines detailed quality improvement initiatives, and we are working with the Trust to gain assurance that progress is being made in the areas defined.” Source location Response from Cambridgeshire and Peterborough ICB
Open published response
Concerns raised 1
Failure to learn from serious incidents and consider recommendations for future care View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Plymouth NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
University Hospitals Plymouth NHS Trust
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
View source
University Hospitals Plymouth NHS Trust
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
View source
University Hospitals Plymouth NHS Trust
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
View source
University Hospitals Plymouth NHS Trust
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
View source
University Hospitals Plymouth NHS Trust
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
View source See 2 more actions
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AI-generated summary
Mary Margaret Pomeroy · 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
Mary Margaret Pomeroy, an 89-year-old hospital inpatient, died after being pushed to the floor by a fellow patient on 3 March 2022, suffering bilateral humeral fractures and deteriorating before her death on 15 March 2022. The inquest found that inadequate assessment and management of the fellow patient’s psychiatric, behavioural and cognitive needs materially contributed to the incident and death. It also identified inadequate analysis of the incident in the hospital’s internal investigation, including failure to identify relevant prior incidents and consider appropriate learning and recommendations.
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× 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 serious incidents and consider recommendations for future care
Wider context from the report “At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022.
The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022.
The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more thoroughly.
The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death.
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS, with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report .
If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur , then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided.
” Source location Mary Margaret Pomeroy · Prevention of Future Deaths report
Open source report
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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 Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
Verbatim wording from the response “4. Recruitment to x2 Learning Response Lead posts.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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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 Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
Verbatim wording from the response “5. Recruitment of two Patient Safety Partners. The remit of the Patient Safety Partner role is set out in the National Patient Safety Strategy through the Framework for Involving Patients in Patient Safety. Patient Safety Partners are lay people, who have extensive experience of receiving care and on occasion, may have been involved in safety incidents. As such, they provide a different perspective on patient safety, removing the potential of influence by organisational bias or historical systems.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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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 Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
Verbatim wording from the response “6. Developed a new policy for the investigation of safety incidents, which includes new investigation methods” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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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 Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
Verbatim wording from the response “7. Redesigned our governance processes to further promote transparency and proactive multidisciplinary review of quality concerns and undertaking assurance work on any actions implemented as a result of those concerns. We have done this by ensuring:” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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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 Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Verbatim wording from the response “In June 2024, in line with other NHS Organisations across England, University Hospitals Plymouth NHS Trust (UHP) transitioned to the use of the Patient Safety Incident Response Framework (PSIRF) and ceased the use of the Serious Incident Framework (SIF).” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 3
Failure of harm-only reporting to identify underlying safety problems View source Failure to learn from identified safety issues and themes View source Inadequate Trust investigations failing to identify safety issues View source
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Lancashire and South Cumbria Integrated Care Board University Hospitals of Morecambe Bay NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
University Hospitals of Morecambe Bay NHS Foundation Trust
Implement PSIRF through proportionate learning responses, co-produced investigations, and training for staff involved in incident responses.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Conduct regular mortality reviews and triangulation meetings to inform governance, training, resourcing and risk-prevention decisions.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Employ three full-time Learning Response Leads to conduct investigations and oversee the PSIRF process.
View source
NHS Lancashire and South Cumbria Integrated Care Board
Operate maternity governance and reporting forums to review incidents, outcomes, investigations, learning and improvement actions across the system.
View source
NHS Lancashire and South Cumbria Integrated Care Board
Scrutinise patient-safety investigation reports and monitor PSIRF implementation through safety-panel attendance, supportive challenge and review of patient and family engagement.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Operate multidisciplinary daily triage and cross-care-group reviews of concerns, incidents and feedback to support early escalation and coordinated learning.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Review embeddedness of the Kirkup recommendations or successor practices through internal audit.
View source
NHS Lancashire and South Cumbria Integrated Care Board
Ensure actions arising from shared-learning discussions are implemented across the system.
View source
Department of Health and Social Care
Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across regional and national NHS services.
View source
University Hospitals of Morecambe Bay NHS Foundation Trust
Embed enhanced quality assurance for Patient Safety Incident Investigations through a structured clinical governance review process.
View source
NHS Lancashire and South Cumbria Integrated Care Board
Obtain the external audit outcome on PSIRF progress and monitor implementation of any resulting action plan.
View source See 9 more actions
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AI-generated summary
Ida Jean Lock · 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
Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.
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× 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 harm-only reporting to identify underlying safety problems
Wider context from the report “15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone , clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery .
” Source location Ida Jean Lock · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to learn from identified safety issues and themes
Wider context from the report “2. ████████s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn . ████████'s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest.
” Source location Ida Jean Lock · Prevention of Future Deaths report
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 Inadequate Trust investigations failing to identify safety issues
Wider context from the report “9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
” Source location Ida Jean Lock · Prevention of Future Deaths report
Open source report
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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 Implement PSIRF through proportionate learning responses, co-produced investigations, and training for staff involved in incident responses.
Verbatim wording from the response “Implementation of the Patient Safety Incident Response Framework (PSIRF)” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Conduct regular mortality reviews and triangulation meetings to inform governance, training, resourcing and risk-prevention decisions.
Verbatim wording from the response “Promoting a Culture of Transparency and Accountability” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Employ three full-time Learning Response Leads to conduct investigations and oversee the PSIRF process.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Operate maternity governance and reporting forums to review incidents, outcomes, investigations, learning and improvement actions across the system.
Verbatim wording from the response “The LMNS, (the maternity arm of the Integrated Care Board) has established and embedded a governance and reporting structure for all local maternity services. This includes a bi-monthly Quality Assurance Panel and Patient Safety Learning Group (see attached Terms of Reference). U H M B T maternity service are fully engaged and provide regular reporting on maternity and neonatal outcomes and patient safety incidents in order to maximise learning across the Integrated Care System (ICS).” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
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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 Scrutinise patient-safety investigation reports and monitor PSIRF implementation through safety-panel attendance, supportive challenge and review of patient and family engagement.
Verbatim wording from the response “As stated earlier in this response the ICB acknowledges that the Trusts journey in implementing and embedding PSIRF, the frameworks principles and the training of investigators in line with national expectations is not as advanced as initially planned or expected. This includes the clear need for compassionate engagement that is timely, open and transparent when care goes wrong. We are re-assured by the Trust that there is a plan in place to address these gaps and will actively and robustly monitor the progress to fully meet the PSIRF expectations using both quantitative and qualitative intelligence sources.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
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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 Operate multidisciplinary daily triage and cross-care-group reviews of concerns, incidents and feedback to support early escalation and coordinated learning.
Verbatim wording from the response “Daily Triage and Cross-Care Group Reviews” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
Verbatim wording from the response “We have undertaken a comprehensive reform of our Trust-wide clinical governance framework. This includes:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 embeddedness of the Kirkup recommendations or successor practices through internal audit.
Verbatim wording from the response “The Board has asked the internal auditors to:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Ensure actions arising from shared-learning discussions are implemented across the system.
Verbatim wording from the response “Additionally, the ICB are sighted on the improvements being made to embed the Patient Safety Incident Response Framework (PSIRF) which is focussed on learning and compassionate engagement. We do however acknowledge that progress with PSIRF has been limited which in turn delays learning and improvements. In order to address this deficit the ICB are aware that additional capacity has now been sought to ensure that investigations into patient safety events are conducted in a timely manner, and this is currently being closely monitored with appropriate challenge provided to the Trust at both internal Trust and external assurance meetings. Within the wider organisation the Trust attend and actively participate in the ICS Shared Learning Forum and Patient Safety Specialist meetings. The ICB will ensure that actions taken from these discussions are implemented.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
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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 Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across regional and national NHS services.
Verbatim wording from the response “I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Ida, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Joint response from DHSC and NHSE
Open published response
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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 Embed enhanced quality assurance for Patient Safety Incident Investigations through a structured clinical governance review process.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
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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 Obtain the external audit outcome on PSIRF progress and monitor implementation of any resulting action plan.
Verbatim wording from the response “It is understood by LSC ICB that Mersey Internal Audit Authority (MIAA) as external auditors are scheduled to undertake an audit on the Trust’s PSIRF progress in 2025/26; the ICB will seek a copy of the audit outcome and monitor the implementation of any resulting action plan.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
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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 University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Verbatim wording from the response “My response therefore focuses on concern D and E. I note that you have also addressed this report to University Hospitals Morecambe Bay NHS Foundation Trust (UHMBT) and NHS Lancashire and South Cumbria Integrated Care Board (LSC ICB). These organisations will address specifics as to the changes being implemented as a result of the Report. NHS England’s response to you is also made on behalf of the Department of Health and Social Care (DHSC), and I understand that they will not therefore be issuing a separate response to the Coroner. With DHSC input, I have also addressed in this response some of your concerns regarding A and B.” Source location Joint response from DHSC and NHSE
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to embed learning from deaths and monitor safety culture View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Nottinghamshire Healthcare NHS Foundation Trust Serco UK & Europe Sodexo
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Serco UK & Europe
Establish and operate a Pan Custodial Safety Lead role to embed safety improvements across custodial sites.
View source
Serco UK & Europe
Continue embedding remedial actions operationally and monitor their implementation through the Pan Custodial Safety Lead.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Establish enhanced Executive-led oversight and assurance reviews for Offender Health and HMP Lowdham Grange.
View source
HM Prison and Probation Service
Establish a meeting focused on addressing issues raised in Reports to Prevent Future Deaths.
View source
HM Prison and Probation Service
Amend future prison competitions to require culture plans and strengthen safety evaluation and safety-risk responses.
View source
HM Prison and Probation Service
Conduct pre-expiry safety audits at private prisons and share reports and recommendations with responsible HMPPS teams.
View source
HM Prison and Probation Service
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
View source
Sodexo
Ringfence key safety tasks and safer-custody staff against future resourcing pressures.
View source See 5 more actions
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AI-generated summary
Anthony Binfield and 2 others · 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
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the risk of future deaths.
” Source location Anthony Binfield and 2 others · Prevention of Future Deaths report
Open source report
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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 Establish and operate a Pan Custodial Safety Lead role to embed safety improvements across custodial sites.
Verbatim wording from the response “practices persist. In light of the concerns that the issues identified, and remedial actions are not fully embedded across our estate we have recently created a new role of Pan Custodial Safety Lead and appointed an Assistant Director with extensive operational experience. She is responsible for driving the safety and well-being of individuals across all custodial sites by leading initiatives that improve outcomes related to self-harm, suicide, violence, and debt. She will assist in chairing the Safety Forum meetings and will liaise with the Inquest solicitor, to ensure that lessons are learned and that improvements are fully embedded operationally following review of investigations, PPO reports, Inquests and any PFDRs issued in the future.” Source location Response from Serco
Open published response
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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 Continue embedding remedial actions operationally and monitor their implementation through the Pan Custodial Safety Lead.
Verbatim wording from the response “practices persist. In light of the concerns that the issues identified, and remedial actions are not fully embedded across our estate we have recently created a new role of Pan Custodial Safety Lead and appointed an Assistant Director with extensive operational experience. She is responsible for driving the safety and well-being of individuals across all custodial sites by leading initiatives that improve outcomes related to self-harm, suicide, violence, and debt. She will assist in chairing the Safety Forum meetings and will liaise with the Inquest solicitor, to ensure that lessons are learned and that improvements are fully embedded operationally following review of investigations, PPO reports, Inquests and any PFDRs issued in the future.” Source location Response from Serco
Open published response
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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 Establish enhanced Executive-led oversight and assurance reviews for Offender Health and HMP Lowdham Grange.
Verbatim wording from the response “Improvement oversight for Offender Health and HMP Lowdham Grange - The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account.” Source location Response from Nottingham NHS
Open published response
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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 Establish a meeting focused on addressing issues raised in Reports to Prevent Future Deaths.
Verbatim wording from the response “The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective mechanism for all those involved in the care of prisoners and to discuss those at risk, share information and ensure a strategic overview that pulls in all relevant information and agencies to ensure support is tailored to the individual. The Governor is committed to learning from deaths that have occurred and has introduced a meeting to focus on work to address issues raised in Reports to Prevent Future Deaths.” Source location Response from HMPPS
Open published response
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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 Amend future prison competitions to require culture plans and strengthen safety evaluation and safety-risk responses.
Verbatim wording from the response “As stated at the inquest, we are committed to learning from the experience of the transfer of Lowdham Grange from one provider to another to inform subsequent competitions for contracts and their mobilisation, and a number of changes have already been made in response.” Source location Response from HMPPS
Open published response
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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 Conduct pre-expiry safety audits at private prisons and share reports and recommendations with responsible HMPPS teams.
Verbatim wording from the response “We have also agreed with the Performance, Assurance, Risk (PAR) Group to conduct Safety Audits at these sites, closer to the mobilisation period. The Safety Audits are usually unannounced, however, given the challenging nature of transferring a site from one Operator to another, we have agreed that these safety audits are carried out 6 – 9 months prior to expiry for these sites (the incumbent operator still won’t be notified prior to them going in). Final” Source location Response from HMPPS
Open published response
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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 Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Verbatim wording from the response “More generally HMPPS is committed to learning from all deaths and to taking action to address any issues that are identified as a result. The Follow-up to Deaths in Custody policy framework describes the early learning review process for all apparently non-natural deaths, through which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the National Safety Group. It also explains our commitment to supporting the various independent investigations processes that follow a death and particularly to meeting our duty of candour, including by disclosing all relevant documents.” Source location Response from HMPPS
Open published response
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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 Ringfence key safety tasks and safer-custody staff against future resourcing pressures.
Verbatim wording from the response “We know that you will share a copy of this response with the families, and we would like to again express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key safety tasks and safer custody staff in the event of changes in resourcing pressures. The implementation of learning from these sad deaths is a priority.” Source location Response from Sodexo
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.