Recurring concern

Unreliable accuracy of safety-review findings and conclusions

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First reported 12 Jun 2018•Latest report 30 Jan 2025

Definition

What this concern includes

Includes failures in formal safety, case or incident reviews that make the findings or conclusions incomplete, inaccurate, partial or insufficiently evidence-based, including omission of material concerns from published summaries and changes based on unrequested or uncertain evidence.

Not included

Excludes failures to conduct, complete or disclose a safety review where the review's findings and conclusions are not themselves deficient.
Excludes failures to implement corrective actions or disseminate established learning after accurate review findings have been produced.
Excludes generic record-keeping, communication or governance deficiencies unless they directly make safety-review findings or conclusions incomplete, inaccurate or inadequately supported.
Excludes ordinary disagreement with a review conclusion where the review considered the material evidence and accurately represented its findings.
Excludes the broader existing concerns about formal safety-incident management, safety-incident investigations and safety-investigation report availability where the specific unsafe condition is not the accuracy or evidential reliability of the findings and conclusions.

Reports: 10
Individual concerns: 10
Date range: 2018–2025
Stated actions: 19

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission2

Nottinghamshire Healthcare NHS Foundation Trust2

Aviva Insurance Limited1

Buckinghamshire Council1

Department of Health and Social Care1

East Lancashire Hospitals NHS Trust1

Epsom Hospital1

Essex Partnership University NHS Foundation Trust1

Family of Paul Barton1

GP1

HM Prison and Probation Service1

London Borough of Bromley1

Midlands Partnership University NHS Foundation Trust1

Mills Family Limited1

Ministry of Defence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

30 Jan2025
Inner South London
Concerns raised1
1. Investigation conclusions based on assumptions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
  Stated by Mills Family LimitedStated completed
AI-generated summary

James Collier SIDDONS · Prevention of Future Deaths report

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

Report summary

James Collier Siddons, who had very severe frailty and multiple co-morbidities, was admitted to hospital after sustaining a fractured left humerus at a nursing home. He subsequently developed aspiration pneumonia and pyelonephritis and died suddenly from sepsis on 31 January 2022. Concerns were raised that the investigation into his fracture was flawed, that the organisation lacked detailed investigation guidance and routine training, and that relevant issues were not communicated promptly by the local authority.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Investigation conclusions based on assumptions
Wider context from the report
“1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt a. It failed to explore all the scenarios that might have accounted for fracture. b. It was in part delegated to a deputy manager without terms of reference c. Mills Family senior management was not involved d. The investigation’s conclusions were based on assumptions ”
Source location
James Collier SIDDONS · 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
Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.

Verbatim wording from the response
“1. To re-emphasise to all managers and deputy managers that all serious incidents should be notified to the senior management team in line with company policies. Further, re-emphasise that input from the Director of Care, Mandy Finn, should be sought before any investigation report or serious incident report is finalised and circulated.”

Source location
Response from Mills Family Ltd
Page 1 · response
Published 30 January 2025
Open published response
17 Jan2024
Nottinghamshire
Concerns raised1
1. Unclear and potentially inaccurate Early Learning Review investigation methodology
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
  Stated by SodexoStated completed
2. Action
  Issue and use national guidance and a standard template to improve the consistency and quality of Early Learning Reviews.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Deliver workshops and feedback to Group Safety Leads to improve their Early Learning Review skills, practice and report writing.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Monitor Early Learning Review quality and share feedback with Group Safety Leads.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Develop a new policy framework that mandates Early Learning Reviews and assigns Prison Group Directors responsibility for checking report quality before sign-off.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Issue a revised Early Learning Review standard template and refreshed guidance alongside the new policy framework.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Kane Christopher Boyce · 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

Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.

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
Unclear and potentially inaccurate Early Learning Review investigation methodology
Wider context from the report
“6. Poor Quality Early Learning Review process, November 2021 While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths. The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm. On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons. It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed. Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self harm. My concerns extend beyond the quality of the report, but also to the accuracy of the same. The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff in particular points in time, yet all prison staff witnesses denied ever having been interviewed as part of the ELR process. It is unclear exactly what methodology the author has used during the investigation. I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset. ”
Source location
Kane Christopher Boyce · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.

Verbatim wording from the response
“Following a death in custody at a Sodexo prison (whilst under Sodexo operational management) an Early Learning Review is required – this should be completed within 7 days. The Early Learning Review notes areas of good practice and recommendations, the Director is expected to ensure that any recommendations are complied with – alongside any recommendations made by the PPO.”

Source location
Response from Sodexo
Page 3 · response
Published 25 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Issue and use national guidance and a standard template to improve the consistency and quality of Early Learning Reviews.

Verbatim wording from the response
“In 2021 the National Safety Team issued guidance and a standard template to assist those conducting the reviews and to bring greater consistency to the reports, which improved the overall quality. Being implemented during the COVID-19 pandemic meant our ability to deliver face-to-face training was limited and as such we have continued to work to improve the quality of ELRs, including holding a workshop with GSLs in July 2022 at which the National Safety Team shared the results of a review of a sample of reports and provided feedback designed to improve practice in the conduct of the reviews and the writing of the reports.”

Source location
Response from HMPPS
Page 1 · response
Published 25 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver workshops and feedback to Group Safety Leads to improve their Early Learning Review skills, practice and report writing.

Verbatim wording from the response
“In 2021 the National Safety Team issued guidance and a standard template to assist those conducting the reviews and to bring greater consistency to the reports, which improved the overall quality. Being implemented during the COVID-19 pandemic meant our ability to deliver face-to-face training was limited and as such we have continued to work to improve the quality of ELRs, including holding a workshop with GSLs in July 2022 at which the National Safety Team shared the results of a review of a sample of reports and provided feedback designed to improve practice in the conduct of the reviews and the writing of the reports.”

Source location
Response from HMPPS
Page 1 · response
Published 25 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor Early Learning Review quality and share feedback with Group Safety Leads.

Verbatim wording from the response
“We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.”

Source location
Response from HMPPS
Page 1 · response
Published 25 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a new policy framework that mandates Early Learning Reviews and assigns Prison Group Directors responsibility for checking report quality before sign-off.

Verbatim wording from the response
“We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.”

Source location
Response from HMPPS
Page 1 · response
Published 25 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Issue a revised Early Learning Review standard template and refreshed guidance alongside the new policy framework.

Verbatim wording from the response
“We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.”

Source location
Response from HMPPS
Page 1 · response
Published 25 January 2024
Open published response
5 Jun2023
Derby and Derbyshire
Concerns raised1
1. Insufficiently robust Trust investigation and review process
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
3. Action
  Continue providing two-day systems-based serious-incident investigation training for investigators.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
1. Action
  Deliver six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
2. Action
  Use developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
AI-generated summary

Jonathan “Jonny” Philip Cole [JC] · 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

Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.

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
Insufficiently robust Trust investigation and review process
Wider context from the report
“6. I have a concern as to the quality of the Trust’s Investigation Report and that the process of review is not sufficiently robust I acknowledge that the Trust recognises that the investigation reports provided in respect of Jonny Cole’s death were unsatisfactory and also and that the review of Rapid Response Liaison Psychiatry involvement in 2022, “was a missed opportunity to retrospectively review the investigation in its entirety”. However, it is of concern that the 2022 review was also insufficient and inadequate. The concerning information relating to the attempt Jonny made to ligate in a tree was not analysed. ████████ told me that an attempt on life by suicide increases the risk 100-fold that you would die by suicide in the next 12 months and is the most significant risk factor in Jonny’s history that massively elevated the risk until that period of time has lapsed which requires clinical risk assessment. The Investigation report and the updated report following review failed to identify themes of concern², and did not reassure me that the Trust had taken an appropriate response to investigate the concerning facts of this case and to ensure lessons were learned and not repeated for other patients and appropriate audit undertaken. I am told that the Trust is, “committed to continuing our improvement journey in this area”, however, I remain concerned that the Trust’s investigation was insufficient, lacked robustness and did not fully engage with the duty of candour. ”
Source location
Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
Page 10 · 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
Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.

Verbatim wording from the response
“The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward.”

Source location
Response from Nottinghamshire Healthcare
Page 5 · response
Published 12 June 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
Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.

Verbatim wording from the response
“The learning from the outcome of this preventing future deaths report will be shared as part of on-going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations.”

Source location
Response from Nottinghamshire Healthcare
Page 5 · response
Published 12 June 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
Continue providing two-day systems-based serious-incident investigation training for investigators.

Verbatim wording from the response
“We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions.”

Source location
Response from Nottinghamshire Healthcare
Page 5 · response
Published 12 June 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
Deliver six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.

Verbatim wording from the response
“We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.”

Source location
Response from Nottinghamshire Healthcare
Page 6 · response
Published 12 June 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
Use developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.

Verbatim wording from the response
“The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums.”

Source location
Response from Nottinghamshire Healthcare
Page 6 · response
Published 12 June 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
Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.

Verbatim wording from the response
“Review of active Investigations & Inquests:”

Source location
Response from Nottinghamshire Healthcare
Page 6 · response
Published 12 June 2023
Open published response
27 Feb2023
Essex
Concerns raised1
1. Failure to maintain reliable investigation conclusions when presented with unrequested and uncertain evidence
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Sharon Elizabeth Langley · 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

Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

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 maintain reliable investigation conclusions when presented with unrequested and uncertain evidence
Wider context from the report
“(7) The Trust investigation author changed the conclusion of his report during the inquest when he received statements provided by staff that were not requested and contained timing information that in evidence staff stated they did not know. ”
Source location
Sharon Elizabeth Langley · 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
Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.

Verbatim wording from the response
“- The weaknesses of the Serious Incident Framework have been nationally recognised, which has led to the implementation of the Patient Safety Incident Response Framework (PSIRF, 2022). EPUT were an early adopter of PSIRF having formally implemented on 1st May 2021, and have helped shape the national implementation expectations. With this in mind, under the Trust’s current Patient Safety Incident Response Plan (PSIRP), an incident of this nature would have been investigated using a revised and recognised methodology and the data in which the investigation would have been set out would allow for a longer period of time to scrutinise the logs against other information to support with a chronology of events, triangulation of events and identification of learning.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 6 · response
Published 7 March 2023
Open published response
2 Dec2022
Buckinghamshire
Concerns raised1
1. Failure to ensure accurate and complete independent review findings are reflected in published case-learning conclusions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Melsadie Adella-Rae Parris · 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

Melsadie Adella-Rae Parris, aged three, died on 18 February 2019 after being struck by a fast non-stopping train at Taplow Railway Station while being held by her adult carer, who also died in a deliberate act of self-harm. The principal concern was that children’s services did not adequately respond to information about the carer’s deteriorating mental health: they did not renew a home visit, seek updated family information, or liaise with mental health services, despite existing guidance encouraging those actions.

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 ensure accurate and complete independent review findings are reflected in published case-learning conclusions
Wider context from the report
“In the course of the investigation and in evidence in the inquest I found that the social work staff in the childrens services were informed on 9th January 2019 by two separate persons, ████████ that the adult with daily care of Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that person admitted to the social worker that the reports were true. The social work team knew that the adult carer had previously been referred to them by emergency services as a result of genuine and valid concerns about the carer’s mental health such that the carer was suffering from psychosis. The team had removed Melsadie appropriately while awaiting a mental health assessment, which was completed without knowledge of the carer’s remark and before the remark was known to children’s services. The mental health assessment found that the carer was not psychotic, an opinion which was appropriate on the day of assessment. The social work team had earlier conducted an investigation around an older matter of concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had arisen two calendar months before the mental health crisis. In respect of that initial concern the social worker had concluded reasonably that there was no evidence to justify the removal of Melsadie nor continuing concern for her safety, but for logistical reasons their file remained open at the time of the new concerns around the carer’s metal health. However the team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to the home, nor seek update information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis. It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer. I found that existing guidance and policy recognised and encouraged the need to engage with family to gather information, to make home visits, to liaise with mental health and to treat assessment decisions and verification of file closure as dynamic processes requiring rigorous scrutiny. However, despite the existence of this guidance, the team placed undue reliance on the opinion of the mental health professionals and on old irrelevant investigations. Furthermore, although the department commissioned an independent review of the case, this found that the death could not have been predicted (which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure to identify the revelations of 9th January 2019. The review report was withheld, following complaints by the family as to matters of fact, but the council decided nonetheless to publish an executive summary which maintained the partial reflection of the review conclusions. I am concerned that by so doing the department will persist in a view that its team did not fail to adhere to its own guidance and good practice. ”
Source location
Melsadie Adella-Rae Parris · Prevention of Future Deaths report
Page 3 · concerns
Open source report
14 Jul2022
Cumbria
Concerns raised1
1. Failure of mortality and harm review to identify the need for a Serious Incident Review
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Gordon Bernard Hendley · 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

Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of mortality and harm review to identify the need for a Serious Incident Review
Wider context from the report
“7) I was shown a “Mortality and Harm Review Tool” completed in May which concluded that “care was good and decisions sound”, and that there was no need for a Serious Incident Review. I stated in court that I completely rejected this. I did however note and am pleased that ████████ is producing an educational programme and Standard operating procedure for SJS/TENS. ”
Source location
Gordon Bernard Hendley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
14 Oct2021
Nottinghamshire
Concerns raised1
1. Failure of investigations to maintain accurate evidence-based findings
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Share investigation learning with staff to reinforce the importance of factual accuracy.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Deliver quality-assurance training for staff approving concise and comprehensive investigation reports.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Paul Ashley Barton · 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

Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of investigations to maintain accurate evidence-based findings
Wider context from the report
“(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case. ”
Source location
Paul Ashley Barton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share investigation learning with staff to reinforce the importance of factual accuracy.

Verbatim wording from the response
“This has been shared with the investigator for their learning and reflection. In the short-term, this will also be raised as a more general lesson learned to remind all staff of the importance of factual accuracy.”

Source location
2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
Page 6 · response
Published 18 October 2021
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
Deliver quality-assurance training for staff approving concise and comprehensive investigation reports.

Verbatim wording from the response
“Quality Assurance of Investigation Reports We also recognised that we also needed to strengthen our overall review of our investigation reports and ensure those individuals who are approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.”

Source location
2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
Page 9 · response
Published 18 October 2021
Open published response
2 Mar2021
Lancashire and Blackburn with Darwen
Concerns raised1
1. Factual inaccuracies in adverse-incident review summaries
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
  Stated by East Lancashire Hospitals NHS TrustStated completed
2. Action
  Develop and use a Serious Incident investigation pro forma with staged sign-off and links between problems, learning and preventive actions.
  Stated by East Lancashire Hospitals NHS TrustStated completed
AI-generated summary

Mr Frank Charles Medley · Prevention of Future Deaths report

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

Report summary

Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

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
Factual inaccuracies in adverse-incident review summaries
Wider context from the report
“(2) The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest. b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance; c. The case was inappropriately allocated to a structured judgement review; d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading; e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor"; iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust); iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest; v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event. f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan; g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services; h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG; i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation; j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day. k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need; l. There was insufficient senior clinical oversight of the conclusions drawn. ”
Source location
Mr Frank Charles Medley · 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
Introduce weekly Executive review of divisional investigations before SIRI Panel submission.

Verbatim wording from the response
“A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 7 · response
Published 8 March 2021
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 and use a Serious Incident investigation pro forma with staged sign-off and links between problems, learning and preventive actions.

Verbatim wording from the response
“A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 7 · response
Published 8 March 2021
Open published response
13 Nov2018
Staffordshire South
Concerns raised1
1. Inaccuracies in serious incident reviews affecting process validity
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Paul Arthur JACKSON · 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

Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

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
Inaccuracies in serious incident reviews affecting process validity
Wider context from the report
“(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process. ”
Source location
Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Jun2018
Surrey
Concerns raised1
1. Failure of the serious incident report to fulfil its learning and accuracy obligations
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
AI-generated summary

Rita Taylor · 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

Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the serious incident report to fulfil its learning and accuracy obligations
Wider context from the report
“7. As was acknowledged in Court, the SI report did not fulfil its obligations and it was agreed that it would be extensively re-written and re-presented to HM Coroner’s Court to more accurately reflect the circumstances of Mrs Taylor’s death and the learning points required to assist in preventing any future deaths. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 5 · 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
Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.

Verbatim wording from the response
“Response - ████████ Associate Medical Director and Responsible Officer, gave evidence in court that the Trust would be reviewing the concerns raised during the inquest process and that we would be preparing a supplemental Root Cause Analysis ‘RCA’ report to address these concerns. A copy of the supplemental RCA report is enclosed and we hope that you agree that the actions and recommendations set out within the Action Plan of this report address the concerns raised within your Report to Prevent Future Deaths.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Investigation conclusions based on assumptions

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Unclear and potentially inaccurate Early Learning Review investigation methodology

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Insufficiently robust Trust investigation and review process

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Failure to maintain reliable investigation conclusions when presented with unrequested and uncertain evidence

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to ensure accurate and complete independent review findings are reflected in published case-learning conclusions

Concerns raised1

Failure of mortality and harm review to identify the need for a Serious Incident Review

Concerns raised1

Failure of investigations to maintain accurate evidence-based findings

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Factual inaccuracies in adverse-incident review summaries

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Actions described in response 6

Actions described in response 6

Actions described in response 1

Actions described in response 2

Actions described in response 2