Recurring concern

Unreliable disclosure of relevant evidence in formal proceedings

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First reported 26 Jul 2016•Latest report 15 Dec 2025

Definition

What this concern includes

Includes failures in formal court, coronial or inquest disclosure processes involving identification, collection, completeness, timeliness, tracking or delivery of safety-relevant evidence and documents, including failure to comply with disclosure orders and omission of relevant document versions or associated concerns.

Not included

Excludes ordinary clinical-record sharing, internal document management and routine inter-service information transfer where no formal proceeding or disclosure obligation is involved.
Excludes failures in investigating an incident or death where the investigation process itself, rather than disclosure of its evidence or documents, is deficient.
Excludes preservation or handling of death-investigation material before disclosure when the existing dedicated death-investigation material concern is the more specific supported boundary.
Excludes failures to act on evidence after it has been completely and timely disclosed.

Reports: 15
Individual concerns: 17
Date range: 2016–2025
Stated actions: 18

Reports 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.

Air Balloon Surgery1

Care Quality Commission1

Care UK1

Central and North West London NHS Foundation Trust1

Chelsea and Westminster Hospital1

Chelsea and Westminster Hospital NHS Foundation Trust1

Cole Valley Care Limited1

Department of Health and Social Care1

East London NHS Foundation Trust1

Home Office1

Midlands Partnership University NHS Foundation Trust1

Ministry of Justice1

NHS England1

Norfolk and Suffolk NHS Foundation Trust1

Norwich Prison1

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.

15 Dec2025
Devon, Plymouth and Torbay
Concerns raised1
1. Failure to provide relevant documentation to the Coroner under Schedule 5 disclosure duties
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lee Kenneth Eustace · 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

Lee Kenneth Eustace was admitted for treatment of oesophageal cancer and underwent a gastro-oesophagectomy with jejunostomy feeding. He developed abdominal pain, but the feed was increased and continued, and he subsequently developed jejunostomy feeding syndrome and bowel ischaemia, dying in intensive care on 1 May 2022. The report raises concerns about an insufficient and partly un followed feeding protocol, and about failures to investigate the incident, comply with the Duty of Candour, and provide relevant information to the Coroner.

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 provide relevant documentation to the Coroner under Schedule 5 disclosure duties
Wider context from the report
“I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirement to do so under Datix. I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths. ”
Source location
Lee Kenneth Eustace · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Dec2024
Inner West London
Concerns raised1
1. Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review internal legal and governance processes to maintain clear records of disclosure.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated in progress
Respondent positions 3
1. Position
  The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
  Stated by NHS EnglandOutside remit
1. Position
  Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
  Stated by NHS EnglandRedirects responsibility
2. Position
  The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
  Stated by Chelsea and Westminster Hospital NHS Foundation TrustDisputes the concern
AI-generated summary

Elton Deutekom · 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

Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.

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 disclose evidence relevant to deaths to the coroner under the duty of candor
Wider context from the report
“2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public, which thus raises the same concern as above. ”
Source location
Elton Deutekom · Prevention of Future Deaths report
Page 4 · 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
Review internal legal and governance processes to maintain clear records of disclosure.

Verbatim wording from the response
“The Trust is reviewing its internal legal and governance processes to ensure clear records of disclosure are maintained so that we may provide assurance should the need arise in future.”

Source location
Response from Chelsea and Westminster NHS Foundation Trust
Page 4 · response
Published 3 December 2024
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 response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.

Verbatim wording from the response
“My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

Source location
Response from NHS England
Page 1 · response
Published 3 December 2024
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
Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.

Verbatim wording from the response
“My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

Source location
Response from NHS England
Page 1 · response
Published 3 December 2024
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 Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.

Verbatim wording from the response
“It is denied that the court was not provided with the evidence it required when requested. As set out below, the Trust has confirmed that disclosure was made at the times requested prior to inquest, on 16 May 2023. Emails confirming this fact are enclosed for the attention of the Coroner. Despite this, the Trust appreciates that there were difficulties in establishing what had been disclosed and when during the hearing, and has fed this back internally.”

Source location
Response from Chelsea and Westminster NHS Foundation Trust
Page 4 · response
Published 3 December 2024
Open published response
14 Oct2024
North Yorkshire and York
Concerns raised1
1. Delays in clear disclosure of reporting errors to families and the Coroner
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update the Incident Management Policy and Compassionate Engagement and Duty of Candour Policy.
  Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.
  Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Submit further Radiology SOP updates for Radiology Directorate review and Care Group Board approval.
  Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated planned
AI-generated summary

Janet Kathleen SEDDON · 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 Kathleen Seddon underwent surgery after a CT scan was re-reviewed and found to show abdominal pathology that had not been identified in the initial report. She deteriorated with signs of sepsis and died in hospital on 9 February 2023. Concerns included the delay in identifying the pathology, the absence of a proper assessment of harm, and delays in disclosing the reporting error to her family and the Coroner.

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 clear disclosure of reporting errors to families and the Coroner
Wider context from the report
“1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death. 2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death. 3. My concerns relate to – a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error; b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error; c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner; d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed; e) the potential risk of death to others in the event of a recurrence of any of the above. ”
Source location
Janet Kathleen SEDDON · 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 the Incident Management Policy and Compassionate Engagement and Duty of Candour Policy.

Verbatim wording from the response
“Following the introduction of the new PSIRF framework the Trust updated the Incident Management Policy and Procedures (March 2024) and its Duty of Candour Policy, now called Compassionate Engagement and Duty of Candour Policy (June 2024) which are available should you wish to have sight of them.”

Source location
Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 15 October 2024
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
Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.

Verbatim wording from the response
“The Trust Radiology Duty of Candour Standard Operating Procedure (SOP) (available should you wish to have sight of this) describes how discrepancies are assessed to establish if radiological errors have occurred and how these are then disclosed to clinicians to evaluate degree of harm and inform duty of candour conversations if required. This SOP is in line with, and applies, national Royal College guidance to our processes. It was last revised in July 2024, before this inquest, and that update included specifying the one-week turnaround timeframe for reporters responding to a candour panel, improving efficiency from the Radiology side of the process, and a two-week response timeframe for treating clinicians to respond to Radiology letters disclosing confirmed radiological errors and requesting feedback on the degree of harm.”

Source location
Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 15 October 2024
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
Submit further Radiology SOP updates for Radiology Directorate review and Care Group Board approval.

Verbatim wording from the response
“Further updates to the SOP have been developed to clarify that the receiving treating clinician’s Care Group governance team should be copied into the initial correspondence to the clinician, and if required escalation for feedback on level of harm will take place with the Cancer, Specialist and Support Services (CSCS) Care Group Director contacting the Director of the respective Care Group. This will ensure a more timely outcome regarding level of harm and in turn a duty of candour conversation with patient and/or family with the treating clinician, supported by a radiologist. These updates will be submitted to the next Radiology Directorate Meeting and on approval to CSCS Care Group Board for virtual agreement on 12/12/24.”

Source location
Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 15 October 2024
Open published response
1 May2024
Norfolk
Concerns raised2
1. Failure to provide complete and relevant document disclosure
2. Failure to scan all document versions onto the electronic system
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Appoint a senior SPOC for every future case with responsibility for ensuring full access to and disclosure of requested documents.
  Stated by Bedfordshire, Cambridgeshire & Norfolk GroupStated planned
2. Action
  Write to all regional sites to remind them to supply requested documentation without delay.
  Stated by Bedfordshire, Cambridgeshire & Norfolk GroupStated planned
AI-generated summary

Mohammed AMIN AZIZI · 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

Mohammed Azizi, who had Crohn’s disease and deep vein thrombosis, repeatedly refused food, monitoring, investigations and treatment while in prison and hospital. He died in hospital on 15 May 2023 from cardiac atrophy and failure, with contributing factors including malnutrition, Crohn’s disease, self-neglect and pulmonary thromboembolism and infarction. The principal concerns related to two versions of an ACCT document, apparent signatures that witnesses said they had not added, possible retrospective reconstruction of records, and incomplete disclosure to the court and the PPO.

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 provide complete and relevant document disclosure
Wider context from the report
“There are also concerns about disclosure of documents and how it came to be that both the Court and the PPO received just one of 2 documents that existed for the same date, and that neither was advised of the concerns previously raised regarding the document that was disclosed. Had the Officer in question not been called to give evidence in Court and her statement simply read in to evidence, the Court would never have been aware of the existence of the second ACCT document, nor the issues surrounding it and nor would the PPO, which is of significant concern. The Court was not provided with evidence to explain how this occurred, who disclosed the document and why they only disclosed one, or how only one came to have been scanned on to the electronic system that was used to then provide disclosure. ”
Source location
Mohammed AMIN AZIZI · Prevention of Future Deaths report
Page 2 · 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 scan all document versions onto the electronic system
Wider context from the report
“There are also concerns about disclosure of documents and how it came to be that both the Court and the PPO received just one of 2 documents that existed for the same date, and that neither was advised of the concerns previously raised regarding the document that was disclosed. Had the Officer in question not been called to give evidence in Court and her statement simply read in to evidence, the Court would never have been aware of the existence of the second ACCT document, nor the issues surrounding it and nor would the PPO, which is of significant concern. The Court was not provided with evidence to explain how this occurred, who disclosed the document and why they only disclosed one, or how only one came to have been scanned on to the electronic system that was used to then provide disclosure. ”
Source location
Mohammed AMIN AZIZI · 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
Appoint a senior SPOC for every future case with responsibility for ensuring full access to and disclosure of requested documents.

Verbatim wording from the response
“• A senior SPOC will always be appointed to any future cases who will have full responsibility for ensuring full access/disclosure of any documents requested. All sites will be written to by the prison group director to remind them of the importance of allowing PPO colleagues unfettered access to documentation.”

Source location
Response from Bedfordshire, Cambridgeshire and Norfolk Group
Page 6 · response
Published 9 May 2024
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
Write to all regional sites to remind them to supply requested documentation without delay.

Verbatim wording from the response
“• Our inquiry found that there were concerns around documentation not being supplied to the PPO to support the completion of the independent review of death in custody. A review of previous deaths in custody has evidenced that this appears to be an isolated case and documentation was supplied as soon as located which unfortunately was post the PPO investigation. This isn’t acceptable, all sites will be written to by the PGD to remind them of their responsibilities in supplying documentation when requested without delay.”

Source location
Response from Bedfordshire, Cambridgeshire and Norfolk Group
Page 5 · response
Published 9 May 2024
Open published response
7 Jul2023
Nottinghamshire
Concerns raised1
1. Delays in identifying and supplying material relevant to inquests
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a core-information checklist and weekly senior oversight of post-incident information collation and storage.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Christopher Howard SMITH · 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 Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

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 identifying and supplying material relevant to inquests
Wider context from the report
“2. An inability to record, retain and supply HM Coroner with material relevant to the inquest The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing. Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time. The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths. An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division. ”
Source location
Christopher Howard SMITH · 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
Implement a core-information checklist and weekly senior oversight of post-incident information collation and storage.

Verbatim wording from the response
“It is with deep regret that we were not able to supply you with the relevant materials to support the Coronial process. We recognise the impact this had on your investigation but also the distress to the family, which is not acceptable. We are committed to improving this process across the Trust to ensure you and your team are provided with all relevant information to support your enquiries, and that there is support for Clinical Teams post serious incident, including where a death has occurred.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 6 November 2023
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
Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.

Verbatim wording from the response
“The Medico Legal Team and senior managers now hold a weekly Inquest Oversight Meeting whereby the specific requirements of each case are reviewed and updated to ensure documents and staff members required are identified and located at an earlier stage of the process. Discussions are held in terms of any witness conflict concerns, noting the important learning that came from Mr Smith’s inquest in this regard. In addition, any staff members not engaging with the process are identified and this is escalated appropriately, with clear guidance that the Trust cannot represent staff members who do not engage with the Trust support in terms of statement provision and preparation for the inquest itself.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 4 · response
Published 6 November 2023
Open published response
8 Nov2022
Inner North London
Concerns raised1
1. Delays in disclosing relevant review information to HM Coroner
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Roy Elton TRAVERS · 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

Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.

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 disclosing relevant review information to HM Coroner
Wider context from the report
“5. As you will be aware, an ancillary function of every inquest is to attempt to learn lessons from the death, the driver behind prevention of future deaths reports. However, it is incumbent upon every hospital trust to consider the deaths of those within its care long before the matter comes to inquest, and to attempt to learn from these if possible. Whittington Health conducted a 72 hour review of Mr Travers’ care on 17 June 2022. This was disclosed to my coroner’s officer late on the afternoon of Friday, 4 November, in preparation for an inquest listed for 10am on Monday, 7 November. This meant that Mr Travers’ family and I received the 72 hour review on the morning of inquest. This had several consequences. • It placed family members in an unfair position in terms of their preparation for inquest. • It did not comply with the duty to co-operate with HM Coroner, not simply when asked but also by volunteering all relevant information. • It denied HMC the ability to call to inquest any witnesses the need for whom only became apparent from the review. • And it did not inspire confidence that Whittington Health took its own review seriously and tried to learn from it. Even the Whittington consultant giving oral evidence at inquest only saw the review on the morning of inquest, and then purely as a result of being provided it by my coroner’s officer. ”
Source location
Roy Elton TRAVERS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
17 Jun2022
Avon
Concerns raised1
1. Failure to disclose incident investigations and related documents to the Coroner’s office
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Donald Gore · 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

Donald Gore acquired a Mycobacterium Chimaera infection during open-heart surgery in November 2016 and died after a prolonged delay in diagnosis. The report describes failures to communicate and recognise the infection risk, delays in testing, and treatment for misdiagnosed sarcoidosis. It also raises concerns that the investigation into the incident was inadequate and was not disclosed to the Coroner’s office.

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 disclose incident investigations and related documents to the Coroner’s office
Wider context from the report
“The evidence demonstrated that the General Practitioner to whom Mr Gore first presented with symptoms on 3.11.17 did not read the alert regarding the risk of Mycobacterium Chimaera infection contained in his GP records, entered in March 2017 further to a letter sent to the practice by the cardiac surgery department. The investigation in response to this is summarised in a document headed “Proforma for completion at SEA/adverse incident meeting” dated 14.1.19. My concerns are - 1. The investigation in response to this incident summarised in that document – a) Does not conform to the usual detail and format of such investigations (eg a Root Cause Analysis), and b) Appeared inadequate; (In addition the investigation and document, or even their existence, were not disclosed to the Coroner’s office despite three GP statements/reports from your practice being requested and provided in the preparation for the Inquest, only being revealed in the course of oral evidence from the GP during the course of the Inquest). ”
Source location
Donald Gore · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Oct2021
Inner North London
Concerns raised1
1. Failure to provide prompt and candid cooperation with coronial inquiries
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Employ four additional Serious Incident investigators to increase investigation capacity and address the backlog.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Clear the accumulated Serious Incident report backlog by the end of 2021.
  Stated by East London NHS Foundation TrustStated in progress
3. Action
  Prioritise Serious Incident investigations with inquest dates and provide realistic due dates for late reports.
  Stated by East London NHS Foundation TrustStated in progress
1. Action
  Provide the Coroner with the 48-hour report when Serious Incident reports are late.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Hire an additional solicitor to increase Legal Affairs Team capacity by late March.
  Stated by East London NHS Foundation TrustStated planned
3. Action
  Chase witness statements and evidence promptly and provide realistic deadlines when delays affect progress.
  Stated by East London NHS Foundation TrustStated planned
4. Action
  Liaise with the Coroner’s Officer to discuss providing transcripts of recorded calls.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Freeda GLAUSIUSZ · 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

Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.

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 provide prompt and candid cooperation with coronial inquiries
Wider context from the report
“2. I heard at inquest that the clinician and his manager had listened to the recording of the call within days of the death and had recognised very significant shortcomings. However, the recording was not volunteered to my coroner’s officer. I was aware of the existence of the call only because ████████ told my officer about it. • I received a copy of the recording of the call (without a transcript) the day before the inquest. • I received a statement from the clinician who took the call the day before the inquest. • I received statements from other ELFT clinicians in dribs and drabs earlier this month. • I received a copy of the SI report the day before the inquest. • I never received a copy of the 48 hour hot de-brief. • Freeda Glausiusz died five months ago. My officer first requested witness statements and a copy of any internal investigation on 7 June, over four months ago, and asked for the statements to be provided by 20 August. This chronology does not demonstrate an eagerness to promote a learning culture by ELFT. The failure to provide prompt and candid co-operation with my office obstructs the coronial inquiry, an inquiry that includes the function of learning from deaths. And it does not demonstrate respect for the family of the deceased. ”
Source location
Freeda GLAUSIUSZ · 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
Employ four additional Serious Incident investigators to increase investigation capacity and address the backlog.

Verbatim wording from the response
“The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Clear the accumulated Serious Incident report backlog by the end of 2021.

Verbatim wording from the response
“The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Prioritise Serious Incident investigations with inquest dates and provide realistic due dates for late reports.

Verbatim wording from the response
“I have sought assurance from the Associate Director of Governance and Risk that until that time, SI investigations with inquest dates will be prioritised and that HM Coroner is provided with realistic due dates if SI reports are going to be submitted to the Coroner’s Court late.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Provide the Coroner with the 48-hour report when Serious Incident reports are late.

Verbatim wording from the response
“Additionally, in the instance that SI reports are late, HM Coroner will be provided with the 48 Hour report.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Hire an additional solicitor to increase Legal Affairs Team capacity by late March.

Verbatim wording from the response
“The Trust has also agreed to hire an additional solicitor in order to increase the Legal Affairs Team’s capacity which has been affected by long term sickness absence and the increase in inquests. A new solicitor will join the team by late March.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Chase witness statements and evidence promptly and provide realistic deadlines when delays affect progress.

Verbatim wording from the response
“In the interim, the Interim Associate Director of Legal Affairs has assured me the Legal Affairs Team will be tasked with diligently chasing up witness statements and evidence such as recordings in a timely manner and provide realistic deadlines to the Coroner’s Officers if issues such as clinician sick leave hinder progress.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
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
Liaise with the Coroner’s Officer to discuss providing transcripts of recorded calls.

Verbatim wording from the response
“I note, the Trust has not previously been requested to provide transcripts of recordings of calls. Going forward, the Interim Associate Director of Legal Affairs will liaise with your Coroner’s Officer’s to discuss how the Trust will provide such a transcript to you.”

Source location
Response from East London NHS Foundation Trust
Page 5 · response
Published 22 June 2023
Open published response
29 Mar2021
Birmingham and Solihull
Concerns raised1
1. Failure to comply with court orders to supply relevant evidence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Return the manager to full-time work at Cole Valley Nursing Home, with daily email checking and ongoing oversight of the implemented measures.
  Stated by Cole Valley Nursing HomeStated completed
AI-generated summary

Raymond Alfred POWELL · 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

Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.

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 comply with court orders to supply relevant evidence
Wider context from the report
“3. The nursing home failed to comply with repeated court orders to supply relevant evidence. On 14 December the nursing home manager was ordered to supply evidence by 18 January. With no response the court order was extended on 8 February to 10 February. One day late, on 11 February, the nursing home manager supplied the witness statements but no documents. On 16 February the nursing home manager was ordered to supply the documents by 23 February. With no response the nursing home manager was served with a schedule 5 notice containing a penal notice to supply the documents by 18 March. In breach of the schedule 5 notice, on 22 March the nursing home manager supplied some but not all documents. I did not accept the reported problem with an email account as justifying the needed failure to comply with court orders for 3 months. ”
Source location
Raymond Alfred POWELL · 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
Return the manager to full-time work at Cole Valley Nursing Home, with daily email checking and ongoing oversight of the implemented measures.

Verbatim wording from the response
“She now understands the importance of reading these reports thoroughly and sending requested documentation as a matter of urgency. ████████ has now returned to Cole Valley Nursing Home full time and will remain at her primary home to ensure that these measures are maintained to a high standard and ensure emails are checked daily and respond more efficiently.”

Source location
2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Page 2 · response
Published 30 March 2021
Open published response
18 Mar2019
Norfolk
Concerns raised1
1. Failure to maintain timely disclosure of all relevant documents
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ellie Jane LONG · 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

Ellie Long was receiving community treatment from the Eating Disorder Service and had diagnoses of Anorexia Nervosa and Depression. She was found hanging in her bedroom on 10 December 2017 and died in hospital on 12 December 2017. The principal concerns were incomplete record keeping and disclosure, and inadequate communication and information sharing with external agencies including her GP and school.

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 maintain timely disclosure of all relevant documents
Wider context from the report
“1. Record keeping and Auditing of Record keeping a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family. b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved. c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT. d) I have concern that full record keeping and disclosure requirements will not remain a priority. ”
Source location
Ellie Jane LONG · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide relevant documentation to the Coroner under Schedule 5 disclosure duties

Concerns raised1

Failure to disclose evidence relevant to deaths to the coroner under the duty of candor

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Delays in clear disclosure of reporting errors to families and the Coroner

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Failure to provide complete and relevant document disclosure

Failure to scan all document versions onto the electronic system

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Delays in identifying and supplying material relevant to inquests

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Delays in disclosing relevant review information to HM Coroner

Concerns raised1

Failure to disclose incident investigations and related documents to the Coroner’s office

Concerns raised1

Failure to provide prompt and candid cooperation with coronial inquiries

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Actions described in response 1

Respondent positions 3

Actions described in response 3

Actions described in response 2

Actions described in response 2

Actions described in response 7