Recurring concern

Failure to establish effective plans to address identified safety concerns

First to latest report 18 Sep 2014 — 6 Jan 2026

Reports that mention this concern
28
Times this concern has been raised
28
Stated actions linked to this concern
67

What this concern includes

Includes failures to establish, specify or assure an effective corrective-action or improvement plan addressing identified safety concerns, service shortcomings or incident learning, including the anchor's failure to address specific service-provision shortcomings and comparable absences of meaningful plans in other reports.

What is not included
  • Excludes failures to implement, complete or deliver actions from an already established safety plan where plan formation is not itself deficient.
  • Excludes inadequate incident investigations where the investigation process, rather than the absence or inadequacy of a resulting improvement plan, is the unsafe condition.
  • Excludes generic governance, oversight or organisational-learning deficiencies unless the report specifically identifies failure to establish a meaningful plan addressing known safety concerns.
  • Excludes ordinary service-improvement planning without an identified patient, public or operational safety concern.

Reports and published responses 28 reports

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

  1. Norfolk

    AI-generated summary

    Tamsin Rebecca Lianne GRUNDY · 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

    Tamsin Rebecca Lianne Grundy, who had a history of depression and was under the care of Mental Health Services, was found dead at home on 26 July 2018 with a weightlifting bar across her neck. Concerns included her difficulty relating to the more than 25 members of the Crisis Resolution Home Treatment Team involved in her care and the lack of a definitive, timed action or named person responsible for addressing this issue.

    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 assign definitive, timed actions and named responsibility for identified care concerns

    Wider context from the report

    “1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service. 2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action. ”

    Source location

    Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Kathleen McGeary · 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

    Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.

    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 clinical and discharge failings through an effective plan

    Wider context from the report

    “5. At Inquest there appeared a culture of acceptance of the above failings and omissions without any corresponding will or effective plan to address them. ”

    Source location

    Kathleen McGeary · 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

    Replace the Symphony-Medisec link with a Medisec Viewer app that launches with Symphony and communicate its required use to all staff.

    Verbatim wording from the response

    “I understand that during the inquest it was noted that a review of the past medical history from available hospital electronic notes (Medisec letter) was not undertaken which led to the ED team not being aware of her hyperparathyroidism. I would respond by saying that while, as heard in evidence, the Locum Doctor did not have access to Medisec, the Division have investigated this and found that the link between Symphony the system in ED and Medisec occasionally can be temperamental although all locums are provided with access to the Medisec system. On March 26 the current link button was removed from the Symphony system and replaced by a Medisec Viewer app that boots at the time Symphony is activated and is available for all to view and so far we have not experienced any problems with this following the update.”

    Source location

    2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
    Page 3 · response
    Published 9 June 2019

    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

    Implement a CDU standard operating procedure defining responsibility across the patient pathway.

    Verbatim wording from the response

    “We have developed a new CDU (Clinical Decision Unit) standard operating procedure, which I attach, where it makes clear where responsibility lies for various aspects of”

    Source location

    2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
    Page 4 · response
    Published 9 June 2019

    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

    Implement a CDU pathway document to support communication between the main hospital department and CDU on admission.

    Verbatim wording from the response

    “the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.”

    Source location

    2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
    Page 5 · response
    Published 9 June 2019

    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

    Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.

    Verbatim wording from the response

    “I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.”

    Source location

    2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
    Page 5 · response
    Published 9 June 2019

    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 developing an electronic CDU discharge summary and put it in place within three months.

    Verbatim wording from the response

    “The Division will continue work on an electronic CDU discharge summary to further enhance the discharge process and aims to have this in place within the next 3 months.”

    Source location

    2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
    Page 6 · response
    Published 9 June 2019

    Open published response

  3. 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

    Delays in formulating action plans after serious incident investigations and reviews

    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

    Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.

    Verbatim wording from the response

    “Moving forward In terms of moving forward a number of actions are being implemented to improve the timeliness of our processes and the development of the action plans:”

    Source location

    2018-0150-Response-by-University-Health-Board
    Page 2 · response
    Published 8 July 2018

    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

    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

    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

    Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.

    Verbatim wording from the response

    “3. A project management approach to be used when conducting a comprehensive investigation with milestones for completion signed up to by the designated Chair (see appendix 2). This approach is not yet in place and will be implemented as part of the revised model described above.”

    Source location

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

    Open published response

  4. Northamptonshire

    AI-generated summary

    Darryl Alfred Wayne Rego SOUZA · 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

    Darryl Alfred Wayne Rego Souza died at the scene on 7 October 2017 from fatal chest injuries sustained when the motorcycle he was riding collided with a Mini at a crossroads in Clipston, Northamptonshire. Concerns included compromised visibility at the junction, the lack of a timeframe for planned improvements to signage and rumble strips, a recommendation that Stop signs be considered, and a further accident at the same location around one week before the resumed inquest.

    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 establish a timeframe for completion of junction safety improvements

    Wider context from the report

    “1. Paragraphs 6.11 – 6.14 of the Forensic Collision Investigator’s report is set out below. 6.11 There is no doubt that the visibility at this junction is compromised by the road geography and as such high visibility “Give Way” signs and crossroads signs together with “SLOW” painted on the road surface serve to highlight the location of the crossroads and the need to take care. 6.12 In view if the visibility at this junction and after reviewing the Collision statistics at this junction there are to be some improvements carried out. 6.13 These improvements include renewing the signing particularly from the Sibbertoft direction and noise or rumble strips to be placed on the road again from the Sibbertoft direction. 6.14 At the time of writing this report, there is no time frame as to when these improvements will be completed. 2. Additionally, during evidence, the Collision Investigator recommended that the junction may benefit from the installation of “Stop” signs. 3. One of the witnesses at the inquest stated that there had been a further accident, at the same location, around one week before the resumed inquest date. ”

    Source location

    Darryl Alfred Wayne Rego SOUZA · 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 yellow-backed warning signs and refresh road markings on the Sibbertoft approach.

    Verbatim wording from the response

    “Soon after the incident our engineering experts attended this particular location and carried out a study of the minor road approach from Sibbertoft (from where Mr Souza emerged just prior to the collision). The current ‘Give Way’ road markings and signage are of regulatory standard. However, a scheme involving the implementation of ‘yellow backed’ signs and refreshed lines is now planned in order to provide an enhanced reminder for inattentive motorists to emphasise the presence of the crossroads and to approach with caution. In order to supplement the signage we will also be introducing a sequence of ‘rumble strips’ in advance of the junction mouth.”

    Source location

    Response from Northamptonshire County Council
    Page 2 · response
    Published 17 June 2018

    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

    Introduce inaudible transverse rumble strips before the junction mouth on the Sibbertoft approach.

    Verbatim wording from the response

    “Soon after the incident our engineering experts attended this particular location and carried out a study of the minor road approach from Sibbertoft (from where Mr Souza emerged just prior to the collision). The current ‘Give Way’ road markings and signage are of regulatory standard. However, a scheme involving the implementation of ‘yellow backed’ signs and refreshed lines is now planned in order to provide an enhanced reminder for inattentive motorists to emphasise the presence of the crossroads and to approach with caution. In order to supplement the signage we will also be introducing a sequence of ‘rumble strips’ in advance of the junction mouth.”

    Source location

    Response from Northamptonshire County Council
    Page 2 · response
    Published 17 June 2018

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Catherine Haf 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

    Catherine Haf Roberts arrived at hospital by ambulance after becoming unwell with persistent diarrhoea and waited outside before remaining in the emergency department for 58 hours because of capacity and ward-space constraints. Her condition deteriorated after transfer to a medical ward, and she died in hospital on 11 February 2016. The principal concern was the continuing lack of an agreed and effective system plan addressing emergency department admission, resource availability and patient flow, which the report states was placing patients’ 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

    Absence of an agreed and effective system plan

    Wider context from the report

    “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests. Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place. ”

    Source location

    Catherine Haf Roberts · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Essex

    AI-generated summary

    Melanie Ellen Lowe · 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

    Melanie Ellen Lowe, who had been sectioned under the Mental Health Act, was found unresponsive in her room on 2 March and later died in hospital after tissues were found obstructing her airway. The inquest concluded that she killed herself and found that her risk of self-harm or suicide had not been properly assessed or reviewed and that adequate precautions had not been taken. The report also raised concern that the trust’s action plan was too basic and lacked detail and supporting evidence.

    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 sufficiently detailed, complete and evidence-supported action planning

    Wider context from the report

    “(1) The trust's action plan is very basic, lacking specific detail. Some elements are blank and there is an absence of supporting evidence. A far more rigorous action plan is required in an effort to prevent future deaths such as Melanie's. ”

    Source location

    Melanie Ellen Lowe · 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

    Update the previous action plan with supporting evidence showing that identified actions have been taken forward.

    Verbatim wording from the response

    “I can confirm that the previous action plan has been updated with supporting evidence to provide assurance that actions have been taken forward. Please find enclosed a copy of the Action Plan, which I hope addresses all of your concerns. I can also confirm that the Trust will complete a further audit to ensure that all the actions identified have been embedded into practice.”

    Source location

    2016-0404-Response
    Page 1 · response
    Published 19 February 2017

    Open published response

  7. Essex

    AI-generated summary

    Margaret Ann Richardson · 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

    Margaret Ann Richardson suffered at least five falls while a patient in Kitwood Ward at St Margaret’s Hospital Epping and died in Princess Alexandra Hospital Harlow after the last fall. The inquest identified failings in implementing the Trust’s falls policy, and the report raised concern about putting in place a robust, comprehensive action plan with timescales.

    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 a robust, comprehensive action plan with timescales

    Wider context from the report

    “(1) a robust, comprehensive Action Plan with timescales’ needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest. ”

    Source location

    Margaret Ann Richardson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Leicester City and South Leicestershire

    AI-generated summary

    Janet Doreen Goodacre · 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

    Janet Doreen Goodacre, aged 88, was admitted to Leicester Royal Infirmary on 1 May 2013 and died there on 21 May 2013 after developing a gastrointestinal bleed while receiving warfarin, deltaparin and aspirin. The report raised concerns that the Trust’s investigation report was factually incorrect and flawed, that its identified root causes were wrong, and that the Trust did not communicate these shortcomings or revisit the report before the inquest.

    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

    Action plans based on erroneous investigation findings

    Wider context from the report

    “I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors. ”

    Source location

    Janet Doreen Goodacre · 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

    Establish named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.

    Verbatim wording from the response

    “The Trust continually works to improve the quality of the investigations of the RCA reports and we have recently introduced three further measures to assist with this.”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 1 · response
    Published 18 September 2014

    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

    Systematically review every action plan and track actions through to full implementation.

    Verbatim wording from the response

    “3. The Trust has established a new ‘Adverse Events Committee’, reporting to the Executive Quality Board, to review all serious untoward events (SUIs).”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 2 · response
    Published 18 September 2014

    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