Recurring concern

Failure to maintain safety risks in corporate risk governance

First to latest report 18 Jan 2017 — 13 Jan 2026

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures involving the corporate risk function, corporate risk register or equivalent corporate risk-governance arrangements when they prevent significant incident circumstances or service safety risks from being escalated, investigated, monitored or retained.

What is not included
  • Excludes generic incident-reporting, documentation or investigation failures that are not explicitly linked to corporate risk governance.
  • Excludes local operational risk assessments or registers unless the concern is specifically about failure to escalate or maintain the risk corporately.
  • Excludes unrelated failures in training, staffing, equipment or clinical controls that are not presented as failures of corporate risk governance.

Reports and published responses 5 reports

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

  1. North Wales (East and Central)

    AI-generated summary

    Rory Colin Williams · 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

    Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.

    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 include endoscopy and gastroenterology service risks on the corporate risk register

    Wider context from the report

    “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:- a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018. b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why. c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks. d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023. e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023. f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known. g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result. ”

    Source location

    Rory Colin Williams · 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

    Review escalation and governance arrangements for gastroenterology-related risks within local and corporate risk management.

    Verbatim wording from the response

    “As part of this work, the Health Board is reviewing the escalation and governance of gastroenterology-related risks to ensure that they are appropriately reflected within local and corporate risk management arrangements and subject to ongoing executive oversight.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 20 January 2026

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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

    Operate joint Army–Capita health-and-safety governance forums and shared risk-management processes.

    Verbatim wording from the response

    “Recruiting Group acts as one entity for health and safety issues through joint (Army and Capita) forums including a Joint Risk Management Board, the Joint Lessons Learned Panel, Clinical Oversight Board, quarterly Joint Health, Safety and Environment reviews and the quarterly Joint Assurance Group. Policies and procedures are reviewed and approved by both partners to ensure clarity and coherence. This joint governance framework supports a proactive and coherent approach to risk management and a more robust, timely and effective response to reported incidents and organisational learning.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 15 · response
    Published 30 December 2019

    Open published response

  3. Manchester South

    AI-generated summary

    Kathleen 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

    Kathleen Smith, who had Alzheimer’s dementia, sustained a hip fracture at her care home on 12 April 2017 after being pushed to the floor by another resident. She underwent surgery, was discharged back to the care home for palliation, and subsequently died. Concerns raised at the inquest included failures to notify her family and the organisation’s corporate risk function, and the lack of audit or review of incidents after the departure of a manager responsible for reporting and escalation.

    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 notify the corporate risk function of incident circumstances

    Wider context from the report

    “In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing. ”

    Source location

    Kathleen Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cumbria

    AI-generated summary

    Michael Parke · Prevention of Future Deaths report

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

    Report summary

    Michael Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of corporate memory for nasogastric tube risks

    Wider context from the report

    “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are: (a) Staff not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy. (d) Staff not following good practice. (e) The Trust not ensuring compliance nor rolling out training to all who needed it. (f) Lack of checks and audits to establish competence and adherence to policy. (g) Failure of the Trust to learn from the first death. (h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register). (i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death. (j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death. (k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust). (l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document. ”

    Source location

    Michael Parke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Cumbria

    AI-generated summary

    Amanda Coulthard · 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

    Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of corporate memory for nasogastric tube safety risks

    Wider context from the report

    “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were: (a) Staff not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy. (d) Staff not following good practice. (e) The Trust not ensuring compliance nor rolling out training to all who needed it. (f) Lack of checks and audits to establish competence and adherence to policy. (g) Failure of the Trust to learn from the first death. (h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register). (i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death. (j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death. (k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust). (l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document. ”

    Source location

    Amanda Coulthard · 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

    Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.

    Verbatim wording from the response

    “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.”

    Source location

    2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Hold organisational briefings in April 2017 to share learning from the Never Events.

    Verbatim wording from the response

    “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.”

    Source location

    2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
    Page 2 · response
    Published 19 February 2017

    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