Recurring concern

Unreliable determination and recording of causes of death

First to latest report 27 Mar 2018 — 10 Mar 2026

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
1

What this concern includes

Includes failures in determining, evidencing, reviewing or recording the cause of death, including inaccurate cause-of-death entries and omissions in coronial or post-mortem investigation that can leave the cause of death incorrectly or insufficiently established.

What is not included
  • Excludes general death notification or verification-record failures where the cause-of-death determination itself is not deficient.
  • Excludes broader coronial autopsy governance, quality-assurance or scientific-update failures unless they directly impair determination of the cause of death.
  • Excludes failures in clinical care before death unless they directly concern establishing the cause of death.
  • Excludes post-death disclosure, inquest or safety-learning failures occurring after the cause of death has been reliably determined and recorded.

Reports and published responses 6 reports

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

  1. East London

    AI-generated summary

    Sheila Creagan · 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

    Sheila Creagan, an 81-year-old woman with heart failure, underwent emergency abdominal surgery in February 2025 and was later admitted with breathing difficulties, anaemia and a suspected gastrointestinal bleed. She died in hospital on 17 March 2025; the inquest determined that untreated and undiagnosed infective endocarditis caused her death. Concerns included the failure to investigate the source of her worsening infection, the missed diagnosis of infective endocarditis, inadequate monitoring of her heart failure, and the decision not to conduct a Patient Safety Framework investigation.

    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 accurately determine and record the cause of death

    Wider context from the report

    “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation. Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with; a. The inaccurate cause of death initially offered by the Trust, b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved. c. The missed diagnosis of infective endocarditis, d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment. ”

    Source location

    Sheila Creagan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns on PSIRF. I note you have also copied your report to Barking, Havering, and Redbridge University Hospitals NHS Trust (BHRUT) who will respond to the broader concerns you have raised.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 March 2026

    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 initial cause of death reflected the best clinical judgment based on information available during life, not a failure in care or decision-making.

    Verbatim wording from the response

    “At the time of death certification and Medical Examiner (ME) scrutiny, there was no clinical evidence during life to suggest bacterial endocarditis. Mrs Creegan had been diagnosed with hospital acquired pneumonia and decompensated heart failure, both of which were supported by contemporaneous clinical findings, blood results, radiological imaging, and physical examination.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 3 · response
    Published 18 March 2026

    Open published response

  2. Cheshire

    AI-generated summary

    Emma Louise MORRISSEY · 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

    Emma Louise Morrissey travelled to Turkey for gastric sleeve surgery and died on 08 July 2022 after an instrument perforated her abdomen during the operation, causing a massive uncontrolled bleed. Concerns included inadequate pre-operative assessment by the health tourism company, unclear health screening questions, lack of investigation into the death, inadequate embalming for repatriation, discrepancies in the surgical records and the reported cause of death, and the absence of platelets despite continued bleeding.

    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 accurately classify and report cause of death

    Wider context from the report

    “5. The cause of death reported in Turkey was natural. It was recorded as 1a, Cardiogenic Shock, due to 1b. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument. ”

    Source location

    Emma Louise MORRISSEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Avon

    AI-generated summary

    Celia Lindsey MARSH · 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

    Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.

    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 obtain and store an early post-death blood sample for later analysis

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Establishing the systems identified by the Coroner falls outside UKHSA’s remit.

    Verbatim wording from the response

    “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.”

    Source location

    Response UK Health Security Agency
    Page 1 · response
    Published 25 November 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

    Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.

    Verbatim wording from the response

    “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.”

    Source location

    Response from Food Standards Agency
    Page 3 · response
    Published 25 November 2022

    Open published response

  4. Surrey

    AI-generated summary

    Connor Samuel Timothy Wellsted · 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

    Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.

    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 inform the autopsy pathologist of the circumstances of a death

    Wider context from the report

    “3. Probity and Investigation by the Children’s Trust, Tadworth The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed. Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death. The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant. ”

    Source location

    Connor Samuel Timothy Wellsted · 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

    Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.

    Verbatim wording from the response

    “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 17 May 2022

    Open published response

  5. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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 produce accurate and satisfactory coronial post-mortem reports

    Wider context from the report

    “1. The quality of the post mortem examination report produced by ████████ was wholly unsatisfactory and proven inaccurate. This meant both the bereaved family and the Trust were initially provided with an inaccurate medical cause of death. As a direct consequence the ability to learn lessons in order to prevent future deaths was not captured in a timely manner. It was not until the Coroner obtained a report from ████████ in 2018 that anaphylaxis was offered as a potential cause of death. Even then, the Court was left having to consider the totality of the evidence and it was not until the inquest that a finding of fact as to the medical cause of death was made. 2. It should be noted the quality of ████████ post mortem practice has been and remains questionable in over 20 Inquests within the North Manchester Coronal area. This is not an isolated case. In this particular case there was clear evidence that the post mortem failings directly impacted on potential lack of clinical learning to prevent future deaths. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Staffordshire South

    AI-generated summary

    Matthew Gayle · 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

    Matthew Gayle, a serving prisoner at HMP Oakwood, was found dead in his cell on 8 December 2016. The precise cause of death could not be determined, although it was considered likely to have been naturally occurring. The report raised concerns that histology had not been carried out during the post-mortem and about the availability, training, appointment, contractual arrangements and fees of consultant histopathologists undertaking coroners’ autopsies.

    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 undertake histology when toxicology is not expected to establish the cause of death

    Wider context from the report

    “Histopathology is very important for determining causes of deaths and it can play a significant role in preventing deaths in the future. When Matthew was found dead he had some illicit drug paraphernalia in one of his hands. He was a young man and the immediate suspicion was that this was a drug related death. The pathologist who conducted the autopsy examined Matthew’s body and took samples for toxicology. Toxicology was carefully carried out (including checking for new psychoactive substances) and the result was that there was nothing in Matthew’s system likely to have caused his death. No histology had been carried out because it was anticipated that toxicology would provide answers. Possibly if histology had been carried out it may have produced a more accurate cause of death for Matthew. I would make it clear that I do not seek to criticise the pathologist in this respect. You will be aware that there are a declining number of consultant histopathologists who are prepared to carry out autopsies for Coroners and many of those who still perform that function are working under substantial pressure. It is important for the proper investigation of death and the prevention of future deaths that there are sufficient histopathologists to carry out autopsies for Coroner when these are required. I would greatly appreciate your assistance with the following: 1. Are active steps being taken to increase the number of consultant histopathologists who will carry out autopsies for Coroners? 2. Will it be a compulsory part of training of doctors who wish to become histopathologists that they do have experience in Coroners’ autopsies? 3. When engaging consultant histopathologists will NHS Trusts appoint doctors who are both competent and willing to carry out autopsies for Coroners? 4. When appointing consultant histopathologists will NHS Trusts ensure that their contractual arrangements enable them to have time to carry out Coroners’ autopsies? 5. Is there any move to increase the fees payable to consultant histopathologists for carrying out Coroners’ autopsies? 6. Are any steps being taken to progress the Hutton report in establishing specialist centres for histopathology? 7. Are you able to provide me with details of any consultant histopathologists who are prepared to carry out autopsies in the large geographical area that I cover? ”

    Source location

    Matthew Gayle · 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