Recurring concern

Unreliable morbidity and mortality review processes

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First reported 13 Apr 2017•Latest report 14 Oct 2025

Definition

What this concern includes

Includes failures in formal morbidity and mortality review processes, including initiating or scheduling reviews, ensuring relevant departments and specialists contribute, conducting meaningful discussion, recording conclusions and learning, and following through required review discussions or actions.

Not included

  • Excludes general clinical governance, incident investigation or organisational-learning failures where no morbidity and mortality review is identified.
  • Excludes failures to implement corrective actions after a morbidity and mortality review has reliably established its findings, unless the review process itself was also deficient.
  • Excludes routine clinical meetings, audits and case discussions that are not formal morbidity and mortality reviews.
  • Excludes the underlying patient-care failure or death where no deficiency in the morbidity and mortality review process is asserted.
Reports
18

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2017–2025

First to latest report issue date

Stated actions
30

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care5
Barts Health NHS Trust2
Care Quality Commission2
North Cumbria Integrated Care NHS Foundation Trust2
Oxford University Hospitals NHS Foundation Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust1
Department for Digital, Culture, Media and Sport1
Faculty of Intensive Care Medicine1
Goring Hall Hospital1
Greater Manchester Health and Social Care Partnership1
Lancashire Teaching Hospitals NHS Foundation Trust1
Medway NHS Foundation Trust1
NHS Central East Integrated Care Board1
NHS England1
NHS Surrey and Sussex Integrated Care Board1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Francis Osborne Barnes · 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

    Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.

    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 record morbidity and mortality meeting minutes

    Wider context from the report

    “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death. I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust. The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital. There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed. There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed. There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death. Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored. It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned. Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar). No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed. We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason. The matters of concern can be summarised as follows: 1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector). 2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients. 3. Consideration of how the Oxford Trust responds to and learns from deaths. ”

    Source location

    Francis Osborne Barnes · 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

    Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.

    Verbatim wording from the response

    “3.1 Future Governance of cross-organisational incidents within TVVN”

    Source location

    Response from Oxford University Hospitals 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

    Amend the OUH Vascular Surgery monthly morbidity and mortality meeting to discuss non-OUH vascular-related deaths.

    Verbatim wording from the response

    “3.1.4 The OUH Vascular Surgery monthly M&M meeting currently reviews all vascular deaths that occur within OUH. This meeting will be amended to discuss non-OUH vascular related deaths to enable learning to be disseminated within OUH.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 5 · response
    Published 6 November 2023

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Jodie Catherine McCann · 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

    Jodie Catherine McCann, a 22-year-old woman, developed gallstone pancreatitis, suffered a cardiac arrest, and required critical care and ventilation. After her tracheostomy tube became displaced and could not be replaced, she suffered a prolonged cardiac arrest caused by lack of oxygen and died. Concerns included inadequate planning and preparation for difficult airway management and tracheostomy displacement, equipment and staffing availability, and delays in the serious incident review.

    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 follow the Mortality Review policy and complete serious incident reviews promptly

    Wider context from the report

    “The Mortality Review policy was not followed, leading to a significant delay in completing the serious incident review, delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at the Trust ”

    Source location

    Jodie Catherine McCann · 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

    Review and revise the mortality governance policy against neighbouring Trusts, national guidance, and identified failings, then seek governance-group approval.

    Verbatim wording from the response

    “Review surrounding Mortality Governance Processes and revision of the Monitoring Mortality and Learning from Review Policy”

    Source location

    Response from University Hospitals of Derby and Burton NHS Foundation Trust
    Page 6 · response
    Published 27 April 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

    Generate and audit 72-hour reports for severe-harm incidents and unexpected deaths to assure proportionate review and compliance.

    Verbatim wording from the response

    “4. For incidents with an actual impact of severe harm/unexpected death or any other incident of concern, these are reviewed at Divisional level and a 72-hour”

    Source location

    Response from University Hospitals of Derby and Burton NHS Foundation Trust
    Page 6 · response
    Published 27 April 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

    Disseminate the revised mortality review policy through Divisional presentations, Trust learning fora, and the Senior Leaders forum.

    Verbatim wording from the response

    “A communications strategy is planned to disseminate the revised Monitoring Mortality and Learning from Deaths Review policy which will include presentation to Divisions and discussion at Trust learning fora including the Learning from Deaths”

    Source location

    Response from University Hospitals of Derby and Burton NHS Foundation Trust
    Page 7 · response
    Published 27 April 2023

    Open published response

  3. West Sussex

    AI-generated summary

    Teegan Marie Barnard · 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

    Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.

    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 undertake anaesthetic morbidity and mortality reviews and share learning

    Wider context from the report

    “3. Investigation after Teegan’s death Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death. Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia. The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing. ”

    Source location

    Teegan Marie Barnard · 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

    Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.

    Verbatim wording from the response

    “The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report.”

    Source location

    Response from St Richards Hospital
    Page 3 · response
    Published 23 January 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

    Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.

    Verbatim wording from the response

    “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 January 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

    Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.

    Verbatim wording from the response

    “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 January 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

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.

    Verbatim wording from the response

    “I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports receive are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 23 January 2023

    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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.

    Verbatim wording from the response

    “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.”

    Source location

    Response from Health Education England
    Page 1 · response
    Published 23 January 2023

    Open published response

  4. Inner North London

    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

    Uncertainty about discussion of patient care at the relevant morbidity and mortality meeting

    Wider context from the report

    “3. The 72 hour review identified the need to discuss Mr Travers’ care at the relevant morbidity and mortality meeting. It is unclear from the review whether that discussion has taken place. ”

    Source location

    Roy Elton TRAVERS · 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

    Collate learning from deaths and report it quarterly to the Trust board-level Quality Assurance Meeting.

    Verbatim wording from the response

    “Mortality review meetings are led by the department mortality leads. There is evidence to support that these meetings are taking place, including provision of timely mortality reviews. These meetings provide opportunities to capture and share the learning from death. This case was discussed at a Mortality Meeting on 21 July 2022. The Associate Medical Director for Patient Safety and Learning from deaths collates the learning and reports this to the Trust board level Quality Assurance Meeting on a quarterly basis. This has continued throughout the COVID-19 pandemic.”

    Source location

    Response from Whittington Health NHS Trust
    Page 3 · response
    Published 9 November 2022

    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

    Existing mortality review meetings and reporting arrangements were considered sufficient to capture and share learning from deaths.

    Verbatim wording from the response

    “Mortality review meetings are led by the department mortality leads. There is evidence to support that these meetings are taking place, including provision of timely mortality reviews. These meetings provide opportunities to capture and share the learning from death. This case was discussed at a Mortality Meeting on 21 July 2022. The Associate Medical Director for Patient Safety and Learning from deaths collates the learning and reports this to the Trust board level Quality Assurance Meeting on a quarterly basis. This has continued throughout the COVID-19 pandemic.”

    Source location

    Response from Whittington Health NHS Trust
    Page 3 · response
    Published 9 November 2022

    Open published response

  5. Manchester South

    AI-generated summary

    Darren Jones · 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

    Darren Jones, who had severe learning disabilities, a long-term catheter and chronic kidney disease, was admitted to Stepping Hill Hospital after unsuccessful catheter changes in the community and Emergency Department. He deteriorated despite treatment for sepsis and died at the hospital on 22 October 2021. The concerns included pressures on community district nursing services, insufficient recognition of his learning difficulties and support needs in hospital, a dispute between Local Authorities affecting respite care and catheter-care training, and the absence of a commissioned LeDeR review.

    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 commission a LeDeR review

    Wider context from the report

    “4. No LeDeR appeared to have been commissioned on the evidence before the Inquest. ”

    Source location

    Darren Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The LeDeR review was held under national and regional guidance during the inquest, and no coroner-requested review was received.

    Verbatim wording from the response

    “No LeDeR Report appeared to have been commissioned in relation to Mr. Jones A LeDeR notification had been made to the system in respect of Mr. Darren Jones. The review was put on 'hold' as per national and regional guidance as the case was being heard at inquest.”

    Source location

    Response from NHS Greater Manchester
    Page 2 · response
    Published 27 September 2022

    Open published response

  6. Cumbria

    AI-generated summary

    Gordon Bernard Hendley · 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

    Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

    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 of mortality and harm review to identify the need for a Serious Incident Review

    Wider context from the report

    “7) I was shown a “Mortality and Harm Review Tool” completed in May which concluded that “care was good and decisions sound”, and that there was no need for a Serious Incident Review. I stated in court that I completely rejected this. I did however note and am pleased that ████████ is producing an educational programme and Standard operating procedure for SJS/TENS. ”

    Source location

    Gordon Bernard Hendley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Mid Kent and Medway

    AI-generated summary

    BETTY ANNIE TADMAN · 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

    Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.

    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 review cases and learn lessons through morbidity and mortality or other forums

    Wider context from the report

    “6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned. ”

    Source location

    BETTY ANNIE TADMAN · 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

    Present the case and learning at a multidisciplinary Grand Round, reminding clinicians to interpret D-Dimers with the recognised screening tool.

    Verbatim wording from the response

    “2.4. The facts and identified failures in this matter will be presented as a case study at a Multi-disciplinary Grand Round session, as soon as they resume, for teaching purposes when clinicians will be reminded that D-Dimers are not to be used in isolation but in conjunction with the recognised screening tool.”

    Source location

    2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 4 February 2021

    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

    Have the Medical Examiner review post-mortem reports and route identified concerns through the Patient Safety and Learning from Deaths programmes.

    Verbatim wording from the response

    “2.6. Since publication in July 2018 of the National Quality Board (NHSE) Learning from Deaths Guidance, the Trust Board is committed to embedding a culture of learning and ensuring effective implementation of all aspects of learning from death. The Trust Mortality Team has initiated a system with the local Coroners Court to ensure all post mortem reports are now disclosed promptly following any patient’s death in hospital. The Medical Examiner also now reviews PM Reports, to ensure that any concerns are highlighted through the Trust’s Patient Safety programme via a link with the Trust Learning from Deaths Team. All post mortems will now be shared with the doctor making the referral to the Coroner and the responsible Consultant.”

    Source location

    2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 4 February 2021

    Open published response

  8. Preston and West Lancashire

    AI-generated summary

    Michael John NEWELL · 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

    Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

    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 obtain ENT input before mortality review conclusions

    Wider context from the report

    “(4) the Trust's ENT team made no input into the mortality review prior to reaching its conclusions. Alternatively, the mortality review team made no request for ENT input prior to reaching its conclusions. Either formulation reduces the effectiveness of the mortality review. ”

    Source location

    Michael John NEWELL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026