Recurring concern

Unreliable national sharing of safety-critical incident information

First to latest report 19 Dec 2013 — 18 Dec 2020

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 1

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 3 reports

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

18 Dec2020
Inner South London
Concerns raised1
1. Absence of a national process and register for food allergy deaths
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Food Standards Agency
Respondent positions 1
1. Food Standards Agency
  Establishing a national register of food-allergy fatalities is outside the respondent’s remit because of other bodies’ medical and clinical responsibilities.
  Outside remit
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
4 Apr2017
South Yorkshire (Western)
Concerns raised1
1. Deficient national guidelines for incident information collation and sharing
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
19 Dec2013
Manchester West
Concerns raised1
1. Failure to share investigation information with interested agencies promptly
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Stated actions 1
1. Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
  Hold the arranged discussion with the MHRA to strengthen future communication and information sharing.
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