Recurring concern

Failure to implement identified safety actions

First to latest report 17 Dec 2013 — 24 Apr 2026

Reports that mention this concern
45
Times this concern has been raised
48
Stated actions linked to this concern
80

What this concern includes

Includes failures to implement, complete or deliver actions arising from incident investigations, root-cause analyses, Trust action plans or other explicit safety action plans, including avoidable delays in completing their outstanding steps.

What is not included
  • Excludes failures to create or sufficiently specify an action plan where no implementation failure is identified.
  • Excludes delays concerning ordinary clinical, infrastructure or administrative tasks that are not identified safety-plan actions.
  • Excludes generic organisational, staffing, training, audit or governance deficiencies unless they are explicitly presented as failures to implement identified safety actions.

Reports and published responses 45 reports

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

  1. Black Country

    AI-generated summary

    Michelle DAWES · 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

    Michelle Dawes was admitted to hospital with worsening symptoms and a large right-sided pleural effusion, but her transfer to the respiratory ward was delayed and a chest drain was never inserted. She deteriorated, suffered a cardiac arrest and died. The principal concerns were missed opportunities and delays in her care, including delayed implementation of changes identified by the Trust, leaving a continuing risk to patient safety.

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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 implement and embed identified patient-safety changes swiftly and effectively

    Wider context from the report

    “1. I am concerned about the fact that the Trust accept there were missed opportunities and delays in the care provided to Mrs Dawes and despite the fact they have identified changes required to improve the care being delivered to their patients, those changes are yet to be implemented and embedded at the Trust. 2. The failure to take swift action to implement change undermines the process of identifying learning from deaths, there is little point knowing what needs to be done to improve patient safety if steps are not taken to implement those changes swiftly and effectively. 3. In this case we are nine months after Mrs Dawes’ death and the evidence heard at inquest was that it could take another three months to implement the changes required. I am concerned that it is going to take the Trust a period of twelve months to implement the changes identified as required as a result of Mrs Dawes’ death and that the risk of future deaths continues in the absence of any interim measures being put in place. ”

    Source location

    Michelle DAWES · 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

    Strengthen the pleural procedures policy with senior escalation, competency-based referral routes, and guidance for bleeding risks and coagulopathy.

    Verbatim wording from the response

    “A Standard Operating Procedure (SOP) aligned with the British Thoracic Society guidance ensuring clear escalation and senior involvement was already in place; following review of the incident learning has been undertaken since Mrs Dawes’s death. This means that amendments to the policy to further strengthen practice in undertaking pleural effusion drainage, has been carried out with the aim and objective being to ensure clear escalation and senior involvement, an amendment has been made to the policy to include guidance on pleural procedures when there is bleeding risk due to medications or coagulopathy (reference page 9 and 10 of the policy).”

    Source location

    Response from Walsall Healthcare NHS Trust
    Page 3 · response
    Published 19 June 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a formal urgency- and clinical-need-based referral process for transferring patients to specialty wards.

    Verbatim wording from the response

    “Following learning from Mrs Dawes’ death we are acting on the principles of the right patient being cared for in the right clinical area and we have introduced a new formal process of patient referrals to specialty ward areas – based on urgency and clinical need. An amendment to the policy has been developed and is in draft format (whilst consultation process is completed).”

    Source location

    Response from Walsall Healthcare NHS Trust
    Page 6 · response
    Published 19 June 2026

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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

    Complete consultation and implementation of the amended specialty-transfer policy, including enhanced review and escalation for patients waiting seven or more days.

    Verbatim wording from the response

    “Following learning from Mrs Dawes’ death we are acting on the principles of the right patient being cared for in the right clinical area and we have introduced a new formal process of patient referrals to specialty ward areas – based on urgency and clinical need. An amendment to the policy has been developed and is in draft format (whilst consultation process is completed).”

    Source location

    Response from Walsall Healthcare NHS Trust
    Page 6 · response
    Published 19 June 2026

    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

    Incorporate incident learning into resident and registrar doctor induction and clinical supervisor discussions.

    Verbatim wording from the response

    “• Learning incorporated into the Resident and Registrar doctors’ induction and clinical supervisor discussions.”

    Source location

    Response from Walsall Healthcare NHS Trust
    Page 8 · response
    Published 19 June 2026

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing senior escalation, operational oversight, communication and specialist referral arrangements provide immediate safety controls while longer-term changes are embedded.

    Verbatim wording from the response

    “3. Delays in implementation and lack of interim safety measures, leading to ongoing risk | Immediate senior escalation routes (ED Consultants, GIM rota, ICU team).”

    Source location

    Response from Walsall Healthcare NHS Trust
    Page 3 · response
    Published 19 June 2026

    Open published response

  2. Buckinghamshire

    AI-generated summary

    Barry HARMER · 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

    Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

    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

    Delays in implementing identified safety actions

    Wider context from the report

    “(5) Evidence from Oxford Health, acknowledged in a candid manner, that the Trust had listened to witnesses and the family during the Inquest and there was more to be taken back to identify further actions to be implemented. The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training going forward. The very fact that learning was still being discussed and identified in January 2026 when Barry died in April 2024 indicates the importance of the timely implementation of identified actions ”

    Source location

    Barry HARMER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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

    Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

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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

    Delays in addressing identified cell-safety concerns

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”

    Source location

    Steven HART · Prevention of Future Deaths report
    Page 3 · 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

    Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.

    Verbatim wording from the response

    “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 3 October 2025

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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

    Carry out daily accommodation fabric checks with additional scrutiny for cell damage or deterioration.

    Verbatim wording from the response

    “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

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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

    Remove cells with significant defects from use and document and monitor remedial work until they are serviceable.

    Verbatim wording from the response

    “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

    Open published response

  4. Avon

    AI-generated summary

    Mabel Olivia 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

    Mabel Olivia Williams was born alive after a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit following severe hypoxic-ischaemic encephalopathy associated with an undiagnosed uterine rupture. The concerns included inadequate information and informed consent about the risks of uterine rupture, failures to recognise or communicate signs of distress in time, and delays in making appropriate changes after serious clinical incidents.

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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

    Delays in implementing appropriate changes following serious clinical incidents

    Wider context from the report

    “Background The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’ The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is. That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby. I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain ████████ informed consent to VBAC, and the shortcomings of the Trust’s patient information leaflets were part of what informed that finding. In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets. When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’. I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients, much to the frustration of the maternity unit. I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved. This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question. Specific concern That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents. ”

    Source location

    Mabel Olivia Williams · Prevention of Future Deaths report
    Page 3 · 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

    Review governance processes to strengthen oversight and accountability for implementing learning and improvement actions.

    Verbatim wording from the response

    “We fully acknowledge the importance of ensuring that learning from serious incidents is translated into practice both promptly and sustainably. To that end, we are undertaking a review of our governance processes to strengthen oversight and accountability for the implementation of learning and improvement actions.”

    Source location

    Response from Great Western Hospitals NHS Foundation Trust
    Page 2 · response
    Published 16 September 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review outstanding serious-incident investigation actions and monitor them through monthly Maternity Governance meetings.

    Verbatim wording from the response

    “In response to the concerns raised, a full review was undertaken of all outstanding actions from the Trust’s serious incident investigations to fully establish the current compliance position and ensure that learning is being translated into meaningful and timely change. To support continued oversight, these actions are reviewed within our monthly Maternity Governance meetings, enabling senior leaders to monitor progress, escalate concerns, and ensure accountability.”

    Source location

    Response from Great Western Hospitals NHS Foundation Trust
    Page 2 · response
    Published 16 September 2025

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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

    Strengthen and embed central tracking and monitoring of serious-incident actions, with prompts, responsibility visibility and progress evidence.

    Verbatim wording from the response

    “To ensure that learning is not only captured but acted upon in a timely and sustained way, we have strengthened our internal systems for tracking and monitoring progress and this revised governance process will be fully embedded by December 2025. Outstanding actions from the Trust’s serious incident investigations are now held within a centralised platform that supports teams with timely prompts and clear visibility of responsibilities. Colleagues across the organisation have been asked to contribute evidence of progress, reflecting our shared commitment to transparency and improvement. Weekly meetings with the Patient Quality,”

    Source location

    Response from Great Western Hospitals NHS Foundation Trust
    Page 2 · response
    Published 16 September 2025

    Open published response

  5. Inner North London

    AI-generated summary

    Louise Elizabeth Amy Crane · 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

    Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.

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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 implement identified risk-reduction actions

    Wider context from the report

    “7) Trust Action Plan Some of the matters contained within the Trust’s action plan, which stems from its own internal investigation, remain outstanding and / or are still awaiting Board level approval. As such, there is some extent, a lack of reassurance (at present) regarding the actions that will actually be taken to address the risks the Trust itself has already identified. ”

    Source location

    Louise Elizabeth Amy Crane · 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

    Review improvement actions through executive-chaired Mandated Support meetings reporting to the Executive Management Committee.

    Verbatim wording from the response

    “4) Ongoing review of all actions at the Mandated Support meetings that are chaired by executives and report to the Executive Management Committee (EMC)”

    Source location

    Response from North London NHS Foundation Trust
    Page 9 · response
    Published 14 July 2025

    Open published response

  6. West London

    AI-generated summary

    Terence William Gillard · 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

    Terence William Gillard was struck by a moving vehicle while crossing the A4 Great West Road at an uncontrolled pedestrian crossing on 11 September 2022. He suffered brain and multiple traumatic injuries and died in hospital on 18 September 2022 from a pulmonary embolism. The concern was that the crossing had no pedestrian traffic lights, demand button or sound signals, and that there was no certainty that proposed safety redesigns would be implemented.

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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

    Lack of certainty that the pedestrian crossing safety redesign will be implemented

    Wider context from the report

    “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane. I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area, making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights. I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past. I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations. I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented. I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction. ”

    Source location

    Terence William Gillard · 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

    Continue working with TfL and stakeholders to secure priority implementation of the proposed pedestrian and cyclist crossing safety measures.

    Verbatim wording from the response

    “- a signal-controlled crossing for pedestrian and cyclists across the A4,”

    Source location

    Response from London Borough of Hounslow
    Page 2 · response
    Published 10 June 2025

    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 formal signalised crossing scheme across the A4 and both sections of Jersey Road, with associated highway-layout amendments.

    Verbatim wording from the response

    “As previously advised at the inquest, we are developing a formal crossing proposal at this location. The proposals are as follows:”

    Source location

    Response from Transport for London
    Page 3 · response
    Published 10 June 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Department does not oversee or consent to TfL’s traffic schemes, including this pedestrian crossing.

    Verbatim wording from the response

    “The highway authority, in this case Transport for London (TfL), is responsible for how traffic is managed on its roads. This includes the design and maintenance of traffic light junctions and any associated pedestrian crossings. While the Department for Transport issues guidance to highway authorities, the Department does not oversee or consent to traffic schemes of this nature.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 10 June 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    TfL and the London Borough of Hounslow are responsible for implementing the crossing redesign, subject to funding and public consultation.

    Verbatim wording from the response

    “I am not aware of any consents required from the Department to enable TfL to make changes to this site. I understand my officials have been in contact with TfL and it has confirmed that the new crossing designs are in TfL and the Borough's gift to implement, subject to funding and public consultation, and no DfT involvement is required.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 10 June 2025

    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

    TfL and the Mayor of London decide, prioritise and approve investment funding for the pedestrian crossing redesign.

    Verbatim wording from the response

    “On the issue of funding, the Government engages regularly with TfL to understand its investment plans and funding requirements. The Government announced £250 million capital funding in December 2023, and a further £485 million for the coming 2025/26 financial year at the Budget, for TfL’s major capital projects. This is in addition to almost £2.2 billion of business rates for transport retained by TfL in 2024/25. The Mayor of London and TfL consider, prioritise and approve its investment decisions. The re-design of the pedestrian crossing would be funded by TfL from revenue sources outside the Department’s funding.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 10 June 2025

    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

    DfT consent is not required, and LBH consent is needed only for minor works on its road network.

    Verbatim wording from the response

    “e. Finally, I turn to your concern that the implementation of TfL’s plans to redesign the pedestrian crossing will not be until 2026 and it remains subject to the consent of the DfT and LBH, the outcome of any public consultation as well as funding considerations. I explain above the steps which must be undertaken, and the timings involved with delivering appropriate and safe improvement works. In relation to consent from LBH, this is only necessary in relation to any minor works on their road network that may be required to facilitate delivery of the wider scheme. In addition, there is no requirement for consent or approvals to be obtained from the DfT.”

    Source location

    Response from Transport for London
    Page 5 · response
    Published 10 June 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Earlier implementation is constrained by required design, modelling, consultation, governance, contractor mobilisation and funding steps.

    Verbatim wording from the response

    “As my colleague ████████ advised during the inquest, it is likely that delivery of the scheme will take place in 2026, to enable time for the completion of traffic modelling, public engagement, concept and detailed design and contractor mobilisation (including relocating any utility services that are required to be moved by statutory undertakers as part of scheme delivery).”

    Source location

    Response from Transport for London
    Page 3 · response
    Published 10 June 2025

    Open published response

  7. Cornwall and Isles of Scilly

    AI-generated summary

    JAMES EDWARD TURNER · 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 Edward Turner died instantly on 25 July 2023 after his motorcycle collided with a grain-laden trailer being towed across the B3252. The substantive concerns were road safety at the collision location, including limited visibility for tractor drivers and speeding, and the fact that recommended road-safety improvements had not been implemented.

    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 implement road safety recommendations at the collision location

    Wider context from the report

    “(1) Road safety at the location of the collision taking account of • the speed limit at the location, • the limited visibility for tractor drivers, • the nature of the tractor loads being conveyed at the collision site and the time it takes for combinations to cross the road, • the data that indicates some motorists are speeding at that location. (2) The fact that the recommendations made by the Council to improve road safety at the collision location have not been implemented. ”

    Source location

    JAMES EDWARD TURNER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. North Wales (East and Central)

    AI-generated summary

    Paul Anthony Roberts · 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 Anthony Roberts took an overdose and inflicted multiple stab wounds in February 2023, after which he received no further mental health support. On 14 August 2023, he attended an emergency department because of deteriorating mental health, but psychiatric assessment was delayed and he left before it took place; he subsequently harmed himself and died on 15 August 2023 from a knife injury to the heart. The substantive concerns were failures in mental health referral and emergency-department care, insufficient accountability for staff actions or omissions, and delays in implementing identified safety measures.

    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

    Delays in acting on identified learning and actions

    Wider context from the report

    “An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED). Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place. My concerns are therefore as follows : 1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients. 2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients. ”

    Source location

    Paul Anthony Roberts · 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

    Provide the patient information leaflet at triage in the Ysbyty Glan Clwyd Emergency Department.

    Verbatim wording from the response

    “With regard to your concerns about the failure to implement improvement actions in a timely manner, I can assure you that the outstanding Patient Information Leaflet is now in place within the Ysbyty Glan Clwyd Emergency Department and is given to patients at the point of triage. Adaptations are currently being made to launch the patient leaflet in both Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments. Completion of this will be monitored via the MHLD Learning and Action Group with an expected completion date of 25th September 2024.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 31 July 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

    Adapt and launch the patient information leaflet in the Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments.

    Verbatim wording from the response

    “With regard to your concerns about the failure to implement improvement actions in a timely manner, I can assure you that the outstanding Patient Information Leaflet is now in place within the Ysbyty Glan Clwyd Emergency Department and is given to patients at the point of triage. Adaptations are currently being made to launch the patient leaflet in both Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments. Completion of this will be monitored via the MHLD Learning and Action Group with an expected completion date of 25th September 2024.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 31 July 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

    Review open action-plan progress and escalate delays through the MHLD Learning and Action Group.

    Verbatim wording from the response

    “The MHLD Learning and Action Group is responsible for the dissemination of learning attained via multiple routes such as investigations, inspections, inquests and mortality reviews. Moving forward this group will review the progression of open action plans and provide timely escalation to facilitate completion.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 31 July 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

    Conduct rolling Datix audits to verify that divisions record, manage and evidence closure of Learning and Improvement Plan actions.

    Verbatim wording from the response

    “As part of the new policy, there are clear accountabilities now set on divisions to deliver the improvement and action plans. The Patient Safety Team, Complaints Team and”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 31 July 2024

    Open published response

  9. Berkshire

    AI-generated summary

    Daniela Vitalia PANI · 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

    Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.

    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 implement identified suicide-risk mitigation measures at the train station

    Wider context from the report

    “The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided. On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing. I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented. ”

    Source location

    Daniela Vitalia PANI · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Essex

    AI-generated summary

    Chloe Anne Tapp · 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

    Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

    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 implement identified actions addressing unsafe neurology practice

    Wider context from the report

    “Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan. Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be. ”

    Source location

    Chloe Anne Tapp · 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

    Continue implementing and monitoring actions from the Serious Incident investigation and neurology improvement action plan.

    Verbatim wording from the response

    “The matters raised in the Consultant’s letter in July 2023 were of great concern. I am aware my colleague Dr David Walker, Chief Medical Officer, wrote to you at the time to confirm the work we were taking to ensure the service was safe, a copy of his letter is attached. Our Serious Incident investigation went on to investigate these concerns, and those findings have informed the detailed action plan attached.”

    Source location

    Response from Mid and South Essex NHS
    Page 4 · response
    Published 6 March 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

    Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.

    Verbatim wording from the response

    “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

    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