Recurring concern

Failure to identify and address recurring safety issues through organisational learning

First to latest report 3 Dec 2013 — 20 May 2026

Reports that mention this concern
62
Times this concern has been raised
68
Stated actions linked to this concern
163

What this concern includes

Includes failures of reporting, review, investigation or organisational-learning processes to recognise substantive safety issues, retain learning from prior concerns, or ensure that identified recurring issues are addressed across the organisation.

What is not included
  • Excludes failures limited to implementing a specific already-defined safety action where no broader failure of organisational learning or issue recognition is identified.
  • Excludes failures of a named clinical, operational or safeguarding system where that system itself supplies the more specific parent boundary.
  • Excludes deficiencies limited to the quality of an individual incident investigation without evidence that safety issues or learning were not identified or addressed more broadly.
  • Excludes generic governance, culture or management concerns without a direct failure to identify, retain or address substantive safety issues.

Reports and published responses 62 reports

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

  1. Berkshire

    AI-generated summary

    Francis Osborne Barnes · 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

    Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.

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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 identify proposed changes after a death

    Wider context from the report

    “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death. I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust. The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital. There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed. There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed. There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death. Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored. It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned. Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar). No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed. We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason. The matters of concern can be summarised as follows: 1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector). 2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients. 3. Consideration of how the Oxford Trust responds to and learns from deaths. ”

    Source location

    Francis Osborne Barnes · Prevention of Future Deaths report
    Page 2 · concerns

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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 and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.

    Verbatim wording from the response

    “3.1 Future Governance of cross-organisational incidents within TVVN”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 3 · response
    Published 6 November 2023

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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 three forms for documenting vascular surgery-related concerns about patient deaths in the Thames Valley.

    Verbatim wording from the response

    “3.1.2 The M&M documentation will include three new forms which will require completion whenever there is a vascular surgery-related concern raised about a patient death in the Thames Valley region.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 4 · response
    Published 6 November 2023

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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

    Maintain the OUH Medical Examiner office to scrutinize all non-Coronial deaths and feed concerns to governance and clinical teams.

    Verbatim wording from the response

    “3.2.3 OUH introduced the Medical Examiner (ME) office in June 2020. This is to provide greater safeguards for the public by ensuring proper scrutiny of all non-Coronial deaths. Currently 100% of Trust deaths are reviewed by the ME office who feedback any concerns directly to the Learning from Deaths team (part of the Clinical Governance team). Any concerns and compliments are also fed back to clinical teams for action.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 5 · response
    Published 6 November 2023

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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

    Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.

    Verbatim wording from the response

    “3.2.8 In response to this inquest several new processes have also been introduced:”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 5 · response
    Published 6 November 2023

    Open published response

  2. Avon

    AI-generated summary

    Gerald Roy Cruse · 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

    Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.

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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 identify and apply learning from falls-related incidents

    Wider context from the report

    “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls. ”

    Source location

    Gerald Roy Cruse · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Create AcciMap and HFACS analyses to identify broader system factors contributing to the fall.

    Verbatim wording from the response

    “To better appreciate the context that this fall occurred within I created an AcciMap and a Human Factors Analysis and Classification System (HFACS) (Appendix One) of the event from the information available.”

    Source location

    Response from Bristol Ambulance
    Page 10 · response
    Published 6 December 2023

    Open published response

  3. Inner South London

    AI-generated summary

    Manoel Messias Santos · 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

    Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.

    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 disseminate and action important learning points

    Wider context from the report

    “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed. 11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction. 12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been. ”

    Source location

    Manoel Messias Santos · 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

    Create and resource a learning team to disseminate learning from probation-involved inquests across the probation service and OMiC model.

    Verbatim wording from the response

    “Separately, a new learning team has also been created and resourced by HMPPS to enable learning from probation-involved inquests to be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.”

    Source location

    Response from HM Prison and Probation Services
    Page 2 · response
    Published 6 October 2023

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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

    Operate the Strategic Improvement Operations team to log, assign, monitor and coordinate recommendations from internal and external investigations and audits.

    Verbatim wording from the response

    “We recognise and regret that this was a significant oversight and have taken immediate steps to address this issue. Following consultation with the PSU we have implemented new commissioning and handling processes to ensure that work commissioned by us from the PSU receives appropriate Director’s attention. Within FNORC a new team, the Strategic Improvement Operations team, has been set up to log, review and track recommendations from all internal and external investigations/audits on our central records. The team is responsible for maintaining a central record of all the recommendations, assigning ownership, monitoring progress and coordinating actions with the central Immigration Enforcement Assurance and Risk team to ensure all FNORC risks are managed through a consistent assurance process and recommendations are implemented in a timely manner.”

    Source location

    Response from Home Office
    Page 4 · response
    Published 6 October 2023

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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

    Share lessons learned from the inquest across Practice Plus Group services.

    Verbatim wording from the response

    “Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Belmarsh. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 6 October 2023

    Open published response

  4. West Yorkshire (Western)

    AI-generated summary

    Leah BARBER · 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

    Leah BARBER, aged 15, was found deceased at Bolton Woods Quarry on 3 June 2019 after falling from a height of around 30 metres. The inquest concluded that Leah had taken her own life. The principal concern was that Bradford Council had no system or single point of oversight providing an overview of its involvement with Leah and similar deaths, limiting its ability to identify and learn lessons and contributing to a risk of future deaths.

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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

    Absence of a single point of oversight for deaths involving previous Council involvement

    Wider context from the report

    “A detailed review of the evidence in this case, which included evidence from two Schools (████████), as well as from Bradford Children's Social Services, the TRACKS Education team (at Bradford Council), the SCIL Team and the Council's SEND Team, revealed that no one person or department at Bradford Council had an overview of Council's involvement in relation to Leah (prior to her death). Of greater concern was that that remained so after each of the Council departments involved were notified that Leah had passed away. Every organisation which had contact with the Coroner's service in relation to Leah's death, with the exception of Bradford Council, was able to provide the Court with an overview/analysis of their involvement with Leah prior to her death and (where appropriate) the lessons they had learnt as a result their involvement with Leah. The Police and the local Mental Health Trust were examples of two public bodies who had and were able to provide an overview/analysis to the Court in terms of their involvement with Leah and confirm whether there were any lessons to be learned by them. The evidence provided by witnesses from the various Bradford Council teams which were involved with Leah, showed a clear disconnect in the involvement of the various Council departments. That was not caused by those individuals who had provided written statements to the Court or the two who attended to provide oral evidence. Whilst the Inquest hearing did not identify actions/omissions on the part of individuals/teams within the Council which more than minimally, negligibly or trivially contributed to Leah's death, the concern is that Bradford Council appeared not to have a system/process in place which allowed anyone (whether an individual / a team) within the Council to have an overview of deaths where there had been previous Council involvement with the deceased (in this case a child). In the apparent absence of such oversight Bradford Council would not be able to learn lessons from such cases (or even know if there were lessons to be learned). The absence of such a single point of oversight as was apparent in Leah's case, contributes to the risk that future deaths could occur unless action is taken. ”

    Source location

    Leah BARBER · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.

    Verbatim wording from the response

    “The Children’s Services Departmental Management Team (DMT) now maintain a risk register to ensure their oversight of any serious incidents or significant events and that current progress is made on identified actions, and that lessons learned are acted on. At the DMT meeting the circumstances of the incident is discussed between the Director of Children’s Services (DCS) and the Assistant Directors (ADs) within Children Services. Where appropriate, actions are agreed, including the team that will coordinate a response. The child remains on the risk register until the actions have been resolved. This change means that the DCS as an individual and the appropriate team asked to coordinate the actions, have oversight and responsibility for those actions.”

    Source location

    Response from City of Bradford Council
    Page 2 · response
    Published 4 August 2023

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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 Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.

    Verbatim wording from the response

    “There have been improvements to the notification process following the death of a child since 2019. Children’s Services Review Guidance (2022) has been produced and this includes a new form and improved processes that systematically collects information within children services when a child has died. This form also seeks to identify systemic issues, key lines of enquiry and provides recommendations. This is coordinated by the Council’s Education Safeguarding Team.”

    Source location

    Response from City of Bradford Council
    Page 2 · response
    Published 4 August 2023

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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 serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.

    Verbatim wording from the response

    “The Serious Incident or Significant Events Guidance, Form and processes, were further developed and implemented in 2020. These processes are used when there is a death of any child, including where abuse or neglect are thought to have contributed to the child’s death. This also includes death by suspected suicide. One of the key changes to the form was the requirement for the relevant Head of Service (HoS) to set out the actions to be taken and for the relevant Assistant Director to give a view about any additional actions need to be taken. This is sent to the DCS to review and is then discussed on Departmental Management Team as outlined earlier. This makes sure that senior leaders in Children’s Services are sighted and reviewing information and decisions about a significant or serious event quickly. This change was put in place in November 2021.”

    Source location

    Response from City of Bradford Council
    Page 2 · response
    Published 4 August 2023

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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 oversight, notification and information-sharing processes are considered sufficient to ensure organisational oversight and learning from child deaths.

    Verbatim wording from the response

    “Having taken time to look into the concerns, I am able to reassure you that following Leah’s death we do now have strengthened processes to make sure that we have organisational oversight where we have more than one team involved and a child dies. We acknowledge that our staff who gave evidence at the inquest did not share the arrangements that have been put in place since Leah’s death.”

    Source location

    Response from City of Bradford Council
    Page 1 · response
    Published 4 August 2023

    Open published response

  5. Norfolk

    AI-generated summary

    Eileen Marguerite WALSH · 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

    Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

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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 accept and learn from identified care concerns

    Wider context from the report

    “9. The Registered Manager did not accept many of the concerns raised by the CQC during their attendance and this is a missed opportunity to learn lessons, improve care and prevent future deaths. ”

    Source location

    Eileen Marguerite WALSH · Prevention of Future Deaths report
    Page 3 · concerns

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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

    Require staff to communicate and manage laundry and medication-room work so resident care, alarm audibility and staff availability are maintained.

    Verbatim wording from the response

    “III. Medication is administered from a mobile secure medication trolley, and the only time that the Senior carer is in the Medication Room is to collect and return the trolley. They are instructed to have the door open whilst they collect and remove the trolley then close and lock it afterwards. Audits on controlled drugs and homely remedies is only completed when both management are on site ensuring that a senior member of staff is able to hear the alarm. Interim monitor system was installed into the medication room until the new monitoring system was fitted.”

    Source location

    Response from Broadland View Care Home
    Page 2 · response
    Published 4 August 2023

    Open published response

  6. Birmingham and Solihull

    AI-generated summary

    Mohammed Khalid HUSSAIN · 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

    Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.

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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 a previous Regulation 28 report

    Wider context from the report

    “5. August 2020 Regulation 28 report: I sent a Regulation 28 report in August 2020 (case of Ian Allen) which identified that there was no system in place to ensure abnormal clozapine levels were escalated and acted upon and that there was a lack of understanding of the importance of clozapine monitoring and how frequently levels should be monitored. Given this report there is a concern that the Trust has not learnt from the previous Regulation 28 report. ”

    Source location

    Mohammed Khalid HUSSAIN · 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

    Implement significant changes to clozapine processes and procedures following the August 2020 report.

    Verbatim wording from the response

    “5. August 2020 Regulation 28 Report”

    Source location

    Response Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 3 · response
    Published 18 July 2023

    Open published response

  7. Nottinghamshire

    AI-generated summary

    Christopher Howard SMITH · 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

    Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

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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 analyse evidence and learn from deaths

    Wider context from the report

    “2. An inability to record, retain and supply HM Coroner with material relevant to the inquest The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing. Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time. The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths. An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division. ”

    Source location

    Christopher Howard SMITH · 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

    Complete a formal review of Offender Health cases requiring coronial processes and undertake further review where identified.

    Verbatim wording from the response

    “You will be aware that we have undertaken a formal review of all Offender Health cases which are due to be heard as a Coronial process and this has identified a number of cases where further review is required. This review recognised that not all investigations unfortunately met the Trust’s high standards of quality, candour and reflection. The further information provided as part of these reviews aims to strengthen our evidence and understand more about the required learning.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 4 · response
    Published 6 November 2023

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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

    Introduce two independent investigators to support Offender Health and lead new serious-incident investigations.

    Verbatim wording from the response

    “I can confirm that moving forward, I have bought in two independent investigators to support and work alongside Offender Health and they will also be allocated new Serious Incident Investigations with the aim of improving, supporting and providing leadership in this area of practice.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 4 · response
    Published 6 November 2023

    Open published response

  8. North West Wales

    AI-generated summary

    Eifion Wyn Huws · 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

    Eifion Wyn Huws, aged 63, died by suicide at his daughter’s home on 10 June 2022 after being found suspended by a ligature. Concerns included the Emergency Department not having access to a very urgent mental-health referral held in hard-copy notes, and delays in completing and sharing the Health Board’s investigation and implementing resulting actions.

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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 identify and address electronic record availability in investigation learning and improvement

    Wider context from the report

    “1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff. It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients. b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement. ”

    Source location

    Eifion Wyn Huws · 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

    Consider and discuss the benefits of integrated IT within the investigation report and subsequent action plan.

    Verbatim wording from the response

    “With regard to the investigation report and action plan into the care and treatment delivered to Mr Huws, the benefits of an integrated IT system should have been considered with reference to the implementation of WCCIS within the action plan and this has been discussed with the investigating officer.”

    Source location

    Response from Betsi Cadwaladr University Local Health Board
    Page 2 · response
    Published 12 June 2023

    Open published response

  9. Manchester South

    AI-generated summary

    Carl Garry 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

    Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

    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 address inadequate leave risk assessment and planning through investigation and learning

    Wider context from the report

    “1. I am concerned that the jury have found that the risk assessments and risk planning for Carl’s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts’ internal investigation conducted by ████████ and I have not received any evidence that there have been reflections or changes following Carl’s death on this issue to reassure me that there is not a continuing risk of future deaths. ”

    Source location

    Carl Garry Thompson · 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

    Hold inpatient learning forums in addition to training meetings to reflect on shared learning, including learning from this case.

    Verbatim wording from the response

    “Further action: - Inpatient Learning forums have been agreed to be held in addition to training ████████ meetings to reflect on shared learning points. The learning from this case is going to be shared in a learning forum on 30/06/2023.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 17 May 2023

    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

    Revisit local support for investigation authors and services to promote active review of action plans and prepare authors to evidence improvements.

    Verbatim wording from the response

    “IR authors required to give evidence will be supported and be prepared to give evidence against the action plan demonstrating improvements in service. To this end, local support has been revisited for Investigation authors, to support active review of action plans with the Investigation author and the services involved.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 5 · response
    Published 17 May 2023

    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

    Develop PSIRF implementation arrangements, including updated investigation templates and support for staff completing investigations.

    Verbatim wording from the response

    “- The trust is considering an updated training offer for authors of investigations with a compassionate, just culture approach. - The Trust has a new PSIRF (Patient Safety Incident Response Framework) implementation group, this was established in February 2023 following a PSIRF trust wide Implementation planning away day. This is looking at the new framework, planning for implementation including updated Investigation templates and support for staff completing these. - Patients Safety training is now available online for all staff to complete. As part of the new PSIRF framework additional training on supporting authors approaching investigations has been offered to staff virtually through 2023. - The Quality team have also planned to share learning slides around preparation for Coroner’s Inquests with staff identified as Investigation authors.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 6 · response
    Published 17 May 2023

    Open published response

  10. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance 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 identify and escalate observation suspension in the 72-hour report

    Wider context from the report

    “6. Governance process failings. a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not. b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action. c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021. d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports. ”

    Source location

    Winbourne Gregory Charles · 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

    Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.

    Verbatim wording from the response

    “2. Implementation of new PSIRF framework, all 72hr reports will be reviewed and signed off by the panel.”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 9 · response
    Published 5 May 2023

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    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