Recurring concern

Failure to include material information in formal statements

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First reported 6 Mar 2015•Latest report 14 Nov 2022

Definition

What this concern includes

Includes failures in preparing, reviewing or serving formal police, clinical, care or organisational statements used for prosecution, investigation or inquest purposes where material factual, clinical or evidential information is omitted or not reliably included.

Not included

Excludes general clinical, care or incident-record deficiencies where the problem is not omission from a formal statement used in a prosecution, investigation or inquest.
Excludes failures to disclose or transmit a complete statement after the statement itself was accurately prepared; those concern disclosure or transfer rather than statement content.
Excludes poor-quality statements where the issue is only style, recollection or lack of detail and no material omission affecting safety, investigation or proceedings is identified.
Excludes failures in the underlying prosecution, clinical care or incident investigation when the formal statement itself is not deficient.

Reports: 5
Individual concerns: 5
Date range: 2015–2022
Stated actions: 1

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.

Department of Health and Social Care1

Lancashire Teaching Hospitals NHS Foundation Trust1

Metropolitan Police Service1

Royal London Hospital1

Sherwood Forest Hospitals NHS Foundation Trust1

United Lincolnshire Teaching Hospitals NHS Trust1

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.

14 Nov2022
East London
Concerns raised1
1. Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification
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.

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

Ghulam Mohammad · 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

Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

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 investigation and inquest reporting to identify enoxaparin use and missing clinical justification
Wider context from the report
“5. Neither the Trust’s initial investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use. ”
Source location
Ghulam Mohammad · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jul2018
Inner North London
Concerns raised1
1. Omission of material information from prosecution statements
This report raised 18 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

Jeroen ENSINK · 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

Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

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
Omission of material information from prosecution statements
Wider context from the report
“2. Police officers at the scene of ████████ arrest took a statement in support of the prosecution of the offence of possession of a bladed article in a public place. However, they missed out a line from the statement that the CPS considered was vital to demonstrating ████████ location when he had the knife. This omission was rectified only months later. ”
Source location
Jeroen ENSINK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Apr2017
Preston and West Lancashire
Concerns raised1
1. Failure to disclose relevant clinical care issues in the ENT consultant's statement
This report raised 13 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

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 disclose relevant clinical care issues in the ENT consultant's statement
Wider context from the report
“(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care. ”
Source location
Michael John NEWELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
6 Mar2015
Central Lincolnshire
Concerns raised1
1. Failure of statements to disclose the lack of support for forceps use to disimpact the fetal head
This report raised 11 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

Thor Harrison Dalhaug · 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

Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of his 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 of statements to disclose the lack of support for forceps use to disimpact the fetal head
Wider context from the report
“(VIII) The fact that none of the statements served by the Trust disclosed that there was no support for the use of forceps to disimpact the fetal head. ”
Source location
Thor Harrison Dalhaug · 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

Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification

Concerns raised1

Omission of material information from prosecution statements

Concerns raised1

Failure to disclose relevant clinical care issues in the ENT consultant's statement

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

Failure of statements to disclose the lack of support for forceps use to disimpact the fetal head

Actions described in response 1