Recurring concern

Unreliable classification and scrutiny of unnatural deaths

First to latest report 4 Sep 2023 — 23 Apr 2025

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures in the classification, reporting or timely scrutiny of deaths identified or potentially identifiable as unnatural, including inaccurate cause-of-death classification and delayed or absent medical-examiner scrutiny of cases reported to the coroner as unnatural.

What is not included
  • Excludes general autopsy, histopathology or toxicology deficiencies unless they directly concern classification or scrutiny of an unnatural death.
  • Excludes generic incident reporting or organisational learning failures that are not part of the formal classification or scrutiny of an unnatural death.
  • Excludes clinical diagnosis or treatment failures where no death-classification, death-reporting or unnatural-death-scrutiny deficiency is identified.

Reports and published responses 2 reports

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

  1. Berkshire

    AI-generated summary

    Lorraine Parker · 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

    Lorraine Parker died on 30 March 2024 after surgery conducted on 23 January 2024; the inquest recorded that her death involved cancer, necessary surgical treatment, and delay in diagnosing and managing an anastomotic leak. The report raises concerns about the Royal Berkshire Hospital’s death investigation processes, including delayed meetings and escalation, poor or defensive structured judgement reviews, unreliable records, and insufficient scrutiny of cases reported 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

    Lack of timely scrutiny of unnatural-death cases reported to the coroner

    Wider context from the report

    “6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost. ”

    Source location

    Lorraine Parker · Prevention of Future Deaths report
    Page 3 · 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

    All three cases received timely, proportionate Medical Examiner scrutiny and appropriate referral or Trust review, so early learning was not lost.

    Verbatim wording from the response

    “6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 6 · response
    Published 24 April 2025

    Open published response

  2. Cheshire

    AI-generated summary

    Emma Louise MORRISSEY · 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

    Emma Louise Morrissey travelled to Turkey for gastric sleeve surgery and died on 08 July 2022 after an instrument perforated her abdomen during the operation, causing a massive uncontrolled bleed. Concerns included inadequate pre-operative assessment by the health tourism company, unclear health screening questions, lack of investigation into the death, inadequate embalming for repatriation, discrepancies in the surgical records and the reported cause of death, and the absence of platelets despite continued bleeding.

    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 accurately classify and report cause of death

    Wider context from the report

    “5. The cause of death reported in Turkey was natural. It was recorded as 1a, Cardiogenic Shock, due to 1b. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument. ”

    Source location

    Emma Louise MORRISSEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026