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.

19 Dec2018
Liverpool and the Wirral
Concerns raised1
1. Incomplete disclosure of casework notes to the inquest
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.

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

Michal Piotr Netyks · 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

Michal Piotr Netyks, a Polish national serving a custodial sentence at HMP Altcourse, died after jumping head first from first-floor railings on 7 December 2017, the day he was due to be released but was instead detained under immigration powers. The report identifies concerns about the timing and explanation of the immigration detention paperwork, access to legal advice and support, the prison railings, and aspects of the Home Office’s handling of the case.

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
Incomplete disclosure of casework notes to the inquest
Wider context from the report
“E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018. The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts... “Hi, Name: Michal Netyks DOB: 10 Aug 1982 Nationality: POL Gender: M System: CID Notes Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17. This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████ Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE Death in Custody case update: Inquest to be listed” ”
Source location
Michal Piotr Netyks · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Nov2018
Staffordshire South
Concerns raised1
1. Difficulty disclosing significant patient documents during the Inquest process
This report raised 10 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

Thomas Paul Arthur JACKSON · 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

Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

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
Difficulty disclosing significant patient documents during the Inquest process
Wider context from the report
“(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process. ”
Source location
Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Feb2017
Buckinghamshire
Concerns raised2
1. Failure to disclose contemporaneous RCA information
2. Failure to coordinate complete and appropriately recorded disclosure for coronial investigations
This report raised 14 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
  Route all future disclosure to the Coroner’s Court through Government Legal Department to avoid confusion.
  Stated by Woodhill PrisonStated planned
AI-generated summary

JACK OLIVER PORTLAND · 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

Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

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 contemporaneous RCA information
Wider context from the report
“(6) Disclosure, initially to the Coroner, of contemporaneous interviews and information gathered during the early stages of the first RCA may have assisted in preventing subsequent delays and progressing the inquest process, enabling learning from any identified concerns to have been addressed at an earlier stage. In any event such notes and related documents did not form part of the disclosure. ”
Source location
JACK OLIVER PORTLAND · Prevention of Future Deaths report
Page 1 · 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 coordinate complete and appropriately recorded disclosure for coronial investigations
Wider context from the report
“(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”
Source location
JACK OLIVER PORTLAND · 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
Route all future disclosure to the Coroner’s Court through Government Legal Department to avoid confusion.

Verbatim wording from the response
“Disclosure We regret that the provision of documents to this inquest was not achieved in the way that we would wish, and would like to apologise to you for the impact that this had on the inquest process. Much of this difficulty arose from the fact that, as Mr Portland died some months after his release from HMP Woodhill and when he was not in prison custody, the usual process by which prisons ensure that the paperwork required for disclosure to assist the Prison and Probation Ombudsman’s investigation and the Coroner’s Inquest is collated was not initiated. In consultation with GLD, we have agreed that in future all disclosure to the Coroner’s Court will be done through GLD to avoid confusion.”

Source location
2017-0049-Response-by-NOMS
Page 3 · response
Published 5 March 2017
Open published response
9 Dec2016
Nottinghamshire
Concerns raised1
1. Witness statements to the coroner omitting relevant trust delay
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 1
1. Action
  Transfer the legal team into the Governance Directorate to strengthen collaboration with the Clinical Governance Unit and support earlier identification of investigation and witness-evidence deficiencies.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
AI-generated summary

Sheila Stokes · 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

Sheila Stokes had a large abdominal aortic aneurysm diagnosed in July 2015 and died at home on 26 January 2016 after it ruptured. The report identified delays in arranging appointments, acting on the radiology alert, discussing the case, and sending information needed for a custom-made graft. It also raised concerns about administrative systems, communication, the trust’s investigation, and the completeness of statements provided 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
Witness statements to the coroner omitting relevant trust delay
Wider context from the report
“5. Nature and content of the witness statements provided to the coroner, which again refer only to delay by the manufacturer, which is clearly not the central issue in this case. ”
Source location
Sheila Stokes · 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
Transfer the legal team into the Governance Directorate to strengthen collaboration with the Clinical Governance Unit and support earlier identification of investigation and witness-evidence deficiencies.

Verbatim wording from the response
“The legal team at Sherwood Forest Hospitals NHS FT is soon to be made part of the Governance Directorate, with offices adjacent. This will enable a greater working relationship between the legal team and the Clinical Governance Unit which it is expected will make matters requiring investigation clearer from the outset. Any insufficiency in witness evidence can be addressed at an earlier stage.”

Source location
2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
Page 5 · response
Published 12 February 2017
Open published response
26 Jul2016
Inner North London
Concerns raised1
1. Delays and failures in disclosing root cause analyses to the coroner
This report raised 8 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

Terence Darren ADAMS · 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

Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

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 and failures in disclosing root cause analyses to the coroner
Wider context from the report
“6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest, and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself. Its existence had not been disclosed to HM Coroner. ”
Source location
Terence Darren ADAMS · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Incomplete disclosure of casework notes to the inquest

Concerns raised1

Difficulty disclosing significant patient documents during the Inquest process

Concerns raised2

Failure to disclose contemporaneous RCA information

Failure to coordinate complete and appropriately recorded disclosure for coronial investigations

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

Concerns raised1

Witness statements to the coroner omitting relevant trust delay

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

Concerns raised1

Delays and failures in disclosing root cause analyses to the coroner

Actions described in response 1

Actions described in response 1