Recurring concern

Unreliable recording of clinical governance meeting concerns and actions

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First reported 27 Oct 2023•Latest report 23 Apr 2025

Definition

What this concern includes

Includes failures in the recording, retention or availability of safety-relevant concerns, discussions, decisions, actions or attendance from explicitly clinical governance, morbidity-and-mortality or comparable safety-review meetings.

Not included

  • Excludes failures to conduct or participate in a meeting where the meeting-recording process itself is not deficient.
  • Excludes ordinary clinical records, patient-care documentation and general record-keeping failures not tied to a clinical governance or safety-review meeting.
  • Excludes academic, administrative or non-safety meetings, including student supervision and routine organisational meetings.
  • Excludes deficiencies in the substantive quality of mortality review, incident investigation or safety action implementation where meeting recording is not the shared unsafe condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2025

First to latest report issue date

Stated actions
6

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.

Oxford University Hospitals NHS Foundation Trust1
Royal Berkshire NHS Foundation 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. Berkshire

    AI-generated summary

    Lorraine Parker · 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

    Lorraine Parker died on 30 March 2024 after surgery conducted on 23 January 2024; the inquest recorded that her death involved cancer, necessary surgical treatment, and delay in diagnosing and managing an anastomotic leak. The report raises concerns about the Royal Berkshire Hospital’s death investigation processes, including delayed meetings and escalation, poor or defensive structured judgement reviews, unreliable records, and insufficient scrutiny of cases reported to the coroner.

    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 records of concerns identified at morbidity and mortality or clinical governance meetings

    Wider context from the report

    “3. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings. ”

    Source location

    Lorraine Parker · 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

    Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.

    Verbatim wording from the response

    “Morbidity and mortality meetings are undertaken in each specialty where a death happens as part of specialty clinical governance processes. A systematic way for teams to capture learning is in place and set out below. The Trust also attaches Appendix 2, a set of forms to support the review process, designed to highlight any issues that may have arisen in care, together with a means of recording any recommendations and actions. This process is well established for specialties including intensive care and renal medicine and has been introduced into M&M meetings for general surgery from May 2025 with the learning captured within the clinical governance minutes. Specialty clinical governance minutes are disseminated to specialty team members by email as well as to the governance team and stored on a Trust shared drive where all specialty clinical governance minutes are held.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 2 · response
    Published 24 April 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

    Disseminate clinical governance learning through specialty teams, governance leads, mortality surveillance and Trust committees.

    Verbatim wording from the response

    “It has been recognised through this inquest process that there are some specialties where there has been a need to support strengthened learning and we can report that this additional support has already been deployed. With regard to meaningful engagement in processes, and how informed discussions and identified learning are captured in clinical governance minutes, senior members of the Trust’s Quality Governance Team have been attending surgery clinical governance meetings to support the learning and have seen evidence of adoption of Trust processes. These meetings, attended by senior surgical consultants, resident (trainee) doctors and other members of the multi-disciplinary team ensuring learning is cascaded throughout the team. Key learning has also been shared with other Specialty Clinical Governance Leads, the Mortality Surveillance Group and other key Trust committees.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 2 · response
    Published 24 April 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

    Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.

    Verbatim wording from the response

    “The specialty is now using the M&M slides (Appendix 2) to capture learning and highlight areas of concerns. Examples are given in Appendix 3 of this. Any challenging areas requiring further discussion will be brought to the next consultant meeting to allow time for full exploration, and the learning brought back to the following governance for dissemination. The documenting and contemporaneous note-taking of these discussions will be by the consultant body. The M&M process within the specialty is currently being restructured to ensure learning points from Structured Judgement Reviews (SJRs)”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 24 April 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

    Store clinical governance discussion notes on a shared drive and provide Legal Services access for future court disclosures.

    Verbatim wording from the response

    “The Trust acknowledges HM Coroner’s concerns that some of these reflections and notes of discussions are not provided timeously to the coroner. The Trust confirms the notes of these discussions will be stored on shared clinical governance drive and the Trust will provide access to the Legal Services Team to these notes so that in future they are available when disclosing medical records to the court. To assist with this, we are developing a checklist of items which may be required for inquests, along with how to locate them on the Trust’s systems.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 4 · response
    Published 24 April 2025

    Open published response

  2. Berkshire

    AI-generated summary

    Francis Osborne Barnes · Prevention of Future Deaths report

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

    Report summary

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

    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 record morbidity and mortality meeting minutes

    Wider context from the report

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

    Source location

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

    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

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

    Verbatim wording from the response

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

    Source location

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

    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

    Amend the OUH Vascular Surgery monthly morbidity and mortality meeting to discuss non-OUH vascular-related deaths.

    Verbatim wording from the response

    “3.1.4 The OUH Vascular Surgery monthly M&M meeting currently reviews all vascular deaths that occur within OUH. This meeting will be amended to discuss non-OUH vascular related deaths to enable learning to be disseminated within OUH.”

    Source location

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

    Open published response
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Data last updated 7 September 2026