Recurring concern

Failure to implement identified safety actions

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First reported 17 Dec 2013•Latest report 24 Apr 2026

Definition

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.

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
45

Distinct published reports

Individual concerns
48

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
80

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB9
Department of Health and Social Care3
British Transport Police2
Care Quality Commission2
Devon Partnership NHS Trust2
First MTR South Western Trains Limited2
NHS England2
North London NHS Foundation Trust2
Oxford Health NHS Foundation Trust2
United Lincolnshire Teaching Hospitals NHS Trust2
Woodhill Prison2
Avenue House Nursing and Care Home1
Axminster Medical Practice1
Barnet Assist1
Barts Health NHS Trust1

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.

  1. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Alun John Davies · 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

    Alun John Davies died instantly after jumping from the platform at Portchester railway station into the path of a non-stopping train on 4 May 2021. The evidence described acute anxiety and chronic depression, following recent personal difficulties. Concerns included limited staffing, CCTV coverage and platform visibility at the station, as well as insufficient public security and welfare announcements and information about obtaining assistance.

    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 fully implement identified station security recommendations

    Wider context from the report

    “(2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented. ”

    Source location

    Alun John Davies · 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

    Install trespass gates, witches hats and anti-tread guards at the ends of Portchester station platforms.

    Verbatim wording from the response

    “18. Response to Paragraph 2: Previous incidents”

    Source location

    Response from South West Trains
    Page 2 · response
    Published 22 September 2022

    Open published response
  2. East London

    AI-generated summary

    Vijaykumar Girishbhai Gadhavi · 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

    Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had 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 action and learning from self-harming incidents

    Wider context from the report

    “1. Datix reports were generated for the multiple self-harming incidents in July and August 2020. There was no evidence at the inquest, that action and learning had been put in place as a result of these incidents. ”

    Source location

    Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. North London

    AI-generated summary

    Sean Ennis · 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

    Sean Ennis was found in his flat after a fire and died in hospital from the consequences of smoke inhalation. The principal concerns included incomplete fire-risk assessment and inadequate smoke detection and telecare arrangements for a vulnerable resident, including the alarm centre not knowing he was a smoker and not responding when he did not answer calls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to address identified fire risks from fire risk assessments

    Wider context from the report

    “1. All Responsible Persons should carry out a comprehensive fire risk assessment that details the fire safety provisions that are in the property and where identified ensure that the recommended safety measures have been applied. It is not appropriate to ‘carry over’ identified actions from one fire risk assessment to another, without addressing those risks. ”

    Source location

    Sean Ennis · 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

    Conduct annual fire risk assessments and assign risk-based target dates to improvements or additional requirements identified.

    Verbatim wording from the response

    “35. NH has carried out a comprehensive Fire Risk Assessment for all of the areas of premises for which it is the Responsible Person. Fire Risk Assessments are reviewed every year at this site, or sooner if there is a significant change in the premises.”

    Source location

    2022-0054-Response-from-Network-Homes_Published.pdf
    Page 7 · response
    Published 24 February 2022

    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

    Responsibility for fire risk assessment at the property is outside the respondent’s ownership and borough remit, except for actions directly affecting its service.

    Verbatim wording from the response

    “1) Whilst the property at Knighleas Court is not within the borough of Barnet, nor owned or managed by Barnet Homes, we undertake to co-operate with any actions carried out as part of a fire risk assessment that directly affect the service provided by Barnet Homes.”

    Source location

    2022-0054-Response-from-Barnet-Homes_Published.pdf
    Page 1 · response
    Published 24 February 2022

    Open published response
  4. East London

    AI-generated summary

    Mr Jason Lennon · 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

    Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.

    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 governance processes to complete serious incident investigation action plans

    Wider context from the report

    “3. The Trust undertook a serious incident investigation report into the events leading to Mr Lennon’s death in November 2019 which made a series of recommendations for action. The action plan was found to have been incomplete by 6/2/22 due to errors attributable to the Trust’s governance team. ”

    Source location

    Mr Jason Lennon · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. North Wales (East and Central)

    AI-generated summary

    Susan Merton · 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

    Susan Merton underwent a CT scan whose report did not identify a common bile duct stone. After the stone was recognised and treatment was scheduled, her condition deteriorated acutely and she died at Glan Clwyd Hospital on 23 August 2019. The report raised concerns that the Health Board had not implemented or reviewed actions from its investigation within its own timeframe, potentially putting lives at risk.

    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 complete actions and recommendations within set timeframes

    Wider context from the report

    “1. Evidence provided to me in the course of the investigation indicated that the Health Board had conducted an investigation and had produced an Action Plan in light of the findings of their investigation. The Action Plan required that the recommendations contained therein be reviewed in a Clinical Governance Meeting on the 5th of August 2021 however for reasons which could not be explained at the inquest, this was not done. 2. On previous occasions I have issued regulation 28 reports expressing concerns that the Health Board continually fail to accomplish actions in circumstances where they have set their own timeframe. 3. I am concerned that as a result of the Health Board failing to follow through with their own actions and recommendations either in a timely manner or in this specific case at all, lives are being put at risk. ”

    Source location

    Susan Merton · Prevention of Future Deaths report
    Page 1 · 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 serious incident investigation reports to undergo Incident Learning Panel scrutiny and approval, with an action plan on the required template.

    Verbatim wording from the response

    “As outlined in my response to the Regulation 28 regarding Mr Hurst, we changed our serious incident process in April 2021. From this date all investigation reports are submitted for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. A report without an action plan would not be accepted. I am very disappointed that our service did not complete an action plan when they should have done, nor was it completed on the right template when it was. Our new process ensures this cannot happen.”

    Source location

    2021-0375-Response-from-BCUHB_Published
    Page 1 · response
    Published 11 November 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

    Track investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.

    Verbatim wording from the response

    “We are also now tracking actions from these investigation reports and action plans through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.”

    Source location

    2021-0375-Response-from-BCUHB_Published
    Page 1 · response
    Published 11 November 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

    Appoint a clinician to review historic action plans and verify action completion and available evidence.

    Verbatim wording from the response

    “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.”

    Source location

    2021-0375-Response-from-BCUHB_Published
    Page 2 · response
    Published 11 November 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

    Continue reviewing historic action plans until prior actions are confirmed complete.

    Verbatim wording from the response

    “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.”

    Source location

    2021-0375-Response-from-BCUHB_Published
    Page 2 · response
    Published 11 November 2021

    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

    Historic action-plan review was temporarily interrupted because the appointed clinician was redeployed to frontline services during the COVID wave.

    Verbatim wording from the response

    “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.”

    Source location

    2021-0375-Response-from-BCUHB_Published
    Page 2 · response
    Published 11 November 2021

    Open published response
  6. North Wales (East and Central)

    AI-generated summary

    Rhian Margaret 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

    Rhian Margaret Roberts was admitted to hospital after being found unresponsive at home following a presumed overdose, with extremely high paracetamol levels identified on admission. ICU clinicians did not become aware of the results until the early hours of the following morning, and she died on 25 November 2020. Concerns included uncertainty about whether a requested toxicology screen was undertaken, delays in approving an updated procedure for communicating life-threatening blood results, and delays in investigating incidents, sharing learning and implementing 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

    Delays in implementing actions following adverse incidents

    Wider context from the report

    “3. I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety. ”

    Source location

    Rhian Margaret Roberts · Prevention of Future Deaths report
    Page 1 · 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

    Upload approved serious-incident actions to Datix, require completion evidence, measure timely closure and audit evidence quality.

    Verbatim wording from the response

    “All actions arising from a serious incident investigation will be uploaded to the Datix incident system on final approval of the investigation by the Corporate Patient Safety Team. Services will upload evidence of completion when closing actions. The timely closure of actions will become a performance measure and audits will take place of submitted evidence to ensure quality and learning.”

    Source location

    2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
    Page 3 · response
    Published 15 July 2021

    Open published response
  7. Lincolnshire

    AI-generated summary

    Vilmantas Venskutonis · 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

    Vilmantas Venskutonis was admitted to Pilgrim Hospital with chest pains, which intensified before he was transferred to Lincoln County Hospital, where he died. The report acknowledges 11 separate intervention opportunities that were missed at Pilgrim. The principal concern was whether a nine-point action plan intended to prevent further deaths had been fully implemented, and, if not, why each point had not been completed.

    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 the action plan in full

    Wider context from the report

    “I refer to the action plan dated December 2019 that was attached to the SI report, Lead Investigator, Dr ████████ (Cardiology). The commencement of the plan is January 2020. There are nine points to this plan, I need to know if the plan has been implemented in full to prevent further deaths with implementation dates for all 9 points. If not implemented in full or in part please state reason why identifying each point. ”

    Source location

    Vilmantas Venskutonis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Nottinghamshire

    AI-generated summary

    Malcolm John Rathmell · 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

    Malcolm Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to implement changes addressing the risk of incorrect prescribing

    Wider context from the report

    “(5) The proposed actions being considered by the Trust to address the issue of incorrect prescribing are in their infancy and other than sharing the learning from the SI report, no other changes or action has been implemented to address the risk of future deaths. ”

    Source location

    Malcolm John Rathmell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  9. Manchester North

    AI-generated summary

    Anne-Marie Nield · 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

    Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her 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 to implement all Domestic Homicide Review and Independent Management Review recommendations

    Wider context from the report

    “6. Whilst the Court recognises that the findings of the Domestic Homicide Review and Independent Management Review were accepted in their entirety by the Force and that some action has been taken since in order to address the shortcomings identified, I am concerned to note that two and a half years since the death of Ms Nield not all the recommendations of the DHR and IMR have yet been implemented. This is potentially putting other victims of domestic violence at risk. ”

    Source location

    Anne-Marie Nield · 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

    Compile recent similar incidents, identify common themes and report learning to the strategic domestic-violence lead.

    Verbatim wording from the response

    “It is acknowledged that despite the aforementioned measures having been introduced that the training and learning has not been thoroughly embedded across GMP. To ensure that the recommendations of past reviews are considered and implemented in full, GMP’s Organisational Learning Board will compile recent similar incidents, look for common themes and report back to the Force’s strategic lead for domestic violence.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 4 · response
    Published 25 January 2019

    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

    The Serious Crime Division Coordination Unit is responsible for coordinating, recording and monitoring actions arising from post-incident recommendations.

    Verbatim wording from the response

    “The Serious Crime Division Coordination (SCD) Unit are responsible for coordinating all recommendations received by GMP as part of any post-incident review or investigation and plan, record and monitor all action which is taken in response to those recommendations.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 4 · response
    Published 25 January 2019

    Open published response
  10. North Wales (East and Central)

    AI-generated summary

    Neville Welton · 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

    Neville Welton attended Wrexham Maelor Hospital on the evening of 12 December 2017 after referral by his GP. Delays in assessment and treatment, associated with capacity and patient flow problems, staffing issues, and administrative and escalation failures, were followed by deterioration and his death in the early hours of the next morning. Concerns included the delay in completing the Health Board’s investigation and action plan, missed implementation timescales, and wider delays in completing serious incident reviews and action plans.

    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 action plans within agreed timescales

    Wider context from the report

    “The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death. I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time. Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans. ”

    Source location

    Neville Welton · Prevention of Future Deaths report
    Page 1 · 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 a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.

    Verbatim wording from the response

    “2. The Health Board is to introduce a weekly Incident Review Meeting (Scoping document Appendix 1) to review on a regular basis all incidents reported on Datix in the previous 7 days. The meeting will be chaired by the Associate Director of Quality Assurance and attended by the senior staff with a specific responsibility for quality and patient safety from each division.”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 3 · response
    Published 8 July 2018

    Open published response
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Data last updated 7 September 2026