Recurring concern

Unreliable national sharing of safety-critical incident information

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First reported 19 Dec 2013•Latest report 18 Dec 2020

Definition

What this concern includes

Includes failures of national or cross-authority arrangements for rapidly collating, updating and sharing safety-critical incident information, including information arising during clinical triage where it is needed by other responsible services or authorities.

Not included

  • Excludes failures limited to creating, documenting or updating an individual clinical record when no national or cross-authority incident-information-sharing deficiency is identified.
  • Excludes generic communication, training, staffing or information-technology deficiencies unless they directly impair the national or cross-authority sharing of safety-critical incident information.
  • Excludes routine information sharing about non-safety matters and failures occurring after relevant incident information has been reliably shared.
  • Excludes separately named information systems or pathways, such as ambulance, prison, mental-health or police systems, when that narrower system is the supported concern.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2020

First to latest report issue date

Stated actions
1

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.

Amey plc1
Department of Health and Social Care1
Eschmann Holdings Limited1
Food Standards Agency1
Medicines and Healthcare products Regulatory Agency1
Ministry of Housing, Communities and Local Government1
Sheffield City Council1
South Yorkshire Police1
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust1
Yorkshire Water Services Limited1

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. Inner South London

    AI-generated summary

    Master Ruben Bousquet · 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

    Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.

    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 a national process and register for food allergy deaths

    Wider context from the report

    “1. Reporting and Registering The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner. The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward. The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA. ”

    Source location

    Master Ruben Bousquet · 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 a national register of food-allergy fatalities is outside the respondent’s remit because of other bodies’ medical and clinical responsibilities.

    Verbatim wording from the response

    “• Separately, whilst it is not within FSA’s remit to establish a national register of fatalities, given their medical and clinical responsibilities in this area, we are discussing with the Department for Health and Social Care (DHSC) how we could analyse and evaluate different data sources to give us a clearer picture of allergic reactions that result in fatality.”

    Source location

    2020-0298-Response-from-Food-Standards-Agency-Redacted
    Page 2 · response
    Published 8 January 2021

    Open published response
  2. South Yorkshire (Western)

    AI-generated summary

    Mr Sean Craig Salvin · 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 Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing 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

    Deficient national guidelines for incident information collation and sharing

    Wider context from the report

    “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents. If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient. ”

    Source location

    Mr Sean Craig Salvin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester West

    AI-generated summary

    Kenneth Smalley · 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

    Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.

    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 share investigation information with interested agencies promptly

    Wider context from the report

    “(4) I have concerns with regard to the Medicines and Healthcare Products Regulatory Agency in relation to contact with all interested Agencies following an investigation to ensure the sharing of information with all interested Agencies particularly to enable lessons to be learned and corrective action to be taken as soon as possible. ”

    Source location

    Kenneth Smalley · 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

    Hold the arranged discussion with the MHRA to strengthen future communication and information sharing.

    Verbatim wording from the response

    “We note in your letter your concerns about communications between the Medicines and Healthcare Products Regulatory Agency and the Trust. We have contacted the MHRA to request a discussion to strengthen communication and sharing of information in the future. We are pleased to confirm that this has been arranged for Monday 10 February 2014.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 3 · response
    Published 19 December 2013

    Open published response
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Data last updated 7 September 2026