Recurring concern

Unreliable completion and receipt of incident review reports

First to latest report 2 Jul 2014 — 30 Jan 2025

Reports that mention this concern
13
Times this concern has been raised
13
Stated actions linked to this concern
14

What this concern includes

Includes failures in the dedicated incident review-report process involving preparation, completion, responsible sign-off, transmission, receipt or tracking of reports needed for safety review and corrective action.

What is not included
  • Excludes failures in the underlying incident investigation or the quality of its analysis where completion or receipt of the report is not deficient.
  • Excludes generic patient-safety incident reporting, post-incident learning or action implementation failures unless the assertion specifically concerns completion or receipt of an incident review report.
  • Excludes ordinary clinical or operational records and reports that are not incident review reports or their directly equivalent safety-review reports.
  • Excludes delays caused solely by external legal, coronial or regulatory proceedings when the incident review-report process itself is not deficient.

Reports and published responses 13 reports

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

  1. Lincolnshire

    AI-generated summary

    Liam Oldsworth · 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

    Liam Oldsworth, a child aged 22 months, was admitted with a high temperature and difficulty breathing and was treated for septicaemia and meningitis, but his condition deteriorated despite medical support. The report raises concern that a Serious Incident Analysis report dated 18/3/2015 was received by the office only within the last week, with recommendations and shared learning attached.

    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 receipt of Serious Incident Analysis reports

    Wider context from the report

    “The Serious Incident Analysis report dated 18/3/2015 has only within the last week been received by this office. Attached are recommendations and shared learning. ”

    Source location

    Liam Oldsworth · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Buckinghamshire

    AI-generated summary

    ARTHUR ALBERT MORLEY · 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

    Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.

    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 cold debriefs and interim incident reports

    Wider context from the report

    “(3) Whilst there was a hot debrief conducted very shortly after Mr Morley’s death, there was no cold debrief and no Serious Incident Report. There is due to be a post-inquest debrief but as issues have emerged during the PFD investigation and the Coroner’s investigation and inquest, the lack of debriefing and interim incident reports delays the implementation of any necessary learning arising as a result of this incident. ”

    Source location

    ARTHUR ALBERT MORLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. North Wales (East and Central)

    AI-generated summary

    Esther Jane Jones · 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

    Esther Jane Jones died at Maelor Hospital, Wrexham, on 30 March 2013. Her death was recorded as due to natural causes, with concerns about missed medication and the process for conducting and completing Serious Incident Reviews, which was said to pose continuing risks to others and may lead to 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 of the process for conducting and completing SIRs

    Wider context from the report

    “That unless steps are taken to improve the process by which SIRs are conducted and completed, then this could pose continuing risks to others and may lead to future deaths. ”

    Source location

    Esther Jane Jones · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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