Recurring concern

Unreliable specialist and forensic support for death investigations

First to latest report 21 Jan 2022 — 11 Dec 2025

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
5

What this concern includes

Includes failures in dedicated specialist homicide, crime-scene-management, forensic pathology or comparable support arrangements for death investigations, including unclear support responsibilities or levels and failure to provide relevant case information needed for specialist forensic work.

What is not included
  • Excludes generic police or organisational investigation deficiencies where no specialist or forensic support failure is identified.
  • Excludes failures in routine clinical care, coronial administration or post-mortem processes where specialist support for a death investigation is not the material concern.
  • Excludes failures occurring after specialist or forensic support has been reliably provided, including disagreements with the resulting professional opinion.
  • Excludes general evidence-gathering or scene-preservation failures unless they directly impair the provision or use of specialist forensic support.

Reports and published responses 5 reports

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

  1. South London

    AI-generated summary

    Mrs Ashana Charles · 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

    Mrs Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.

    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 retain infusion equipment and supplies for forensic investigation

    Wider context from the report

    “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation. 2. ████████, expert pharmacist and pharmaceutical regulator drew attention to a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN). b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management. c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance. d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies. e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance. ”

    Source location

    Mrs Ashana Charles · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Lewis Dean JOHNSON · 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

    Lewis Johnson died aged 18 as a consequence of a road traffic collision while riding a motorcycle during a police pursuit in London on 9 February 2016. The inquest identified that the forensic collision investigation had not been instructed to measure the distance between the pursuing police vehicle and the motorcycle, leaving the jury without clear objective evidence on that 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 include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference

    Wider context from the report

    “At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursuing vehicle and the subject vehicle at points when the two appeared to be closer together. Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit. ”

    Source location

    Lewis Dean JOHNSON · 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

    Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.

    Verbatim wording from the response

    “We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.”

    Source location

    Response from Independent Office for Police Conduct
    Page 2 · response
    Published 29 May 2025

    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

    Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.

    Verbatim wording from the response

    “We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.”

    Source location

    Response from Independent Office for Police Conduct
    Page 1 · response
    Published 29 May 2025

    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

    Distance measurement may not be possible or proportionate in every road traffic collision investigation because the process can be complicated and time-consuming.

    Verbatim wording from the response

    “The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straightforward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.”

    Source location

    Response from Independent Office for Police Conduct
    Page 2 · response
    Published 29 May 2025

    Open published response

  3. Lancashire and Blackburn with Darwen

    AI-generated summary

    Ida Jean Lock · 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

    Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.

    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 assured ongoing funding for MSNI investigations

    Wider context from the report

    “18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children. 19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths. ”

    Source location

    Ida Jean Lock · Prevention of Future Deaths report
    Page 9 · 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

    Nationally led MSNI funding prevents assurance about funding continuing beyond 2027.

    Verbatim wording from the response

    “E. Funding for MSNI”

    Source location

    Response from NHS Lancashire and South Cumbria Integrated Care Board
    Page 7 · response
    Published 26 March 2025

    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 fully inform forensic pathology experts about relevant equipment involvement in 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 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

    Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.

    Verbatim wording from the response

    “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.”

    Source location

    Response from The Children's Trust
    Page 8 · response
    Published 17 May 2022

    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

    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. East London

    AI-generated summary

    Anthony Walgate and 3 others · 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

    Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor were four young men who were drugged with GHB and murdered. The report raises concerns about serious investigative failings, including how sudden deaths were categorised, the allocation and support of homicide investigations, leadership, recording and review of investigative actions, handwriting verification, death notifications and the response to coroners’ concerns. It also identifies concern that users of the Sleepyboy website could engage escorts without verifying their identities.

    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 clarity about specialist and forensic support available when BCU retains primacy

    Wider context from the report

    “It remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU (MC2B). ”

    Source location

    Anthony Walgate and 3 others · Prevention of Future Deaths report
    Page 11 · 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 Investigative Supervisor/Manager Programme and APP for Investigation to specify appropriate sources and levels of specialist support.

    Verbatim wording from the response

    “In their letter to Chief Constables, the NPCC national lead for homicide investigation will be requesting they undertake the appropriate action to ensure national guidance is shared and understood within their police force and to assure themselves that the policies followed in the force or collaborative arrangements, provide the appropriate clarity and specialist support for investigators.”

    Source location

    2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
    Page 7 · response
    Published 25 January 2022

    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

    Design a formal lesson plan on specialist homicide, forensic and crime-scene support and include it in DC, DS, DI and SIO training.

    Verbatim wording from the response

    “Presently there is no formal lesson plan or training provided to staff in relation to the levels of support that they can expect to receive from specialist homicide investigators, crime scene managers or other forensic practitioners in the investigation of deaths, which remain on BCU for progression.”

    Source location

    2022-0017-Response-from-MPS_Published
    Page 3 · response
    Published 25 January 2022

    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