Recurring concern

Failure to reliably translate safety recommendations into actionable changes

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First reported 24 Jul 2017•Latest report 19 May 2023

Definition

What this concern includes

Includes failures in the dedicated process for considering safety recommendations and their implications, communicating them to affected services or personnel, defining actionable changes and assigning responsibility for resulting safety improvements, including the anchor’s failure to evidence consideration of neonatal issues.

Not included

  • Excludes failures limited to implementing already-defined safety actions where recommendation translation and action definition were adequate; those belong to implementation concerns.
  • Excludes failures to verify compliance or effectiveness after safety changes have been implemented; those belong to post-implementation assurance concerns.
  • Excludes generic organisational learning, communication or governance deficiencies where no safety recommendation or resulting change is identified.
  • Excludes the underlying clinical or operational hazard when no deficiency in processing or acting on a safety recommendation is asserted.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2017–2023

First to latest report issue date

Stated actions
3

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.

Bedfordshire Police1
Birmingham City Council1
Birmingham Community Healthcare NHS Foundation Trust1
Cater Link Limited1
Department of Health and Social Care1
National Police Chiefs’ Council1
North West Anglia NHS Foundation Trust1
The Olive School, Small Heath1

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. Cambridgeshire and Peterborough

    AI-generated summary

    Amelia Barbosa · 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

    Amelia Barbosa suffered an acute hypoxic injury immediately before delivery that continued during resuscitation, and she died in hospital on 13 December 2020 at 7 days old. Concerns included unreliable cord blood sampling, delays in obtaining vascular access and administering treatment, inadequate consideration of blood transfusion before resuscitation stopped, and delayed effective cooling. The report also raised concerns that learning and training on these issues had not been fully implemented.

    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 consider neonatal issues arising from the recommendations

    Wider context from the report

    “2. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops. The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action. ”

    Source location

    Amelia Barbosa · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    John Abrahams (Jack) · 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 Abrahams was 20 years old when he took his own life by self-ligature. He had previously received a six-month course of isotretinoin for acne, but the available evidence did not meet the required standard to show a causative link between the treatment and his suicide. The principal concern was that, more than a year after the Isotretinoin Expert Working Group completed its report, its recommendations had still not been implemented, and a further working group to consider implementation had yet to meet.

    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 convene the working group required to consider implementation of the IEWG recommendations

    Wider context from the report

    “The Commission for Human Medicine (CHM) established an Isotretinoin Expert Working Group (IEWG) in response to concerns about psychiatric events. The IEWG considered oral and written evidence over 2020 and 2021. The findings and recommendations of the IEWG were presented in a report to the CHM at the end of 2021 and include a recommendation which relates to prescribing for patients under the age of 18. It is now over a year since the IEWG report was completed and the recommendations have still not been implemented. In that time there have been 45 adverse Isotretinoin events reported to the Medicines Healthcare products Regulatory Agency (MHRA) comprising of 81 psychiatric adverse events, one of which was an attempted suicide. The Court heard that a second working group is required to consider how to implement the IEWG recommendations and that this group has yet to meet. ”

    Source location

    John Abrahams (Jack) · Prevention of Future Deaths report
    Page 1 · 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

    Continue the Implementation Working Group’s work to develop the practical arrangements for safely introducing the isotretinoin recommendations.

    Verbatim wording from the response

    “The CHM further advised in August 2022 that, in order to ensure the safe and effective introduction of the recommendations, an Implementation Working Group should be established with representation from the wider healthcare system in addition to relevant”

    Source location

    Response from Medicines and Healthcare products Regulatory Agency 1
    Page 1 · response
    Published 24 February 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

    Establish and convene an Implementation Working Group to develop the practical implementation of isotretinoin safety recommendations.

    Verbatim wording from the response

    “The CHM further advised that, in order to ensure the safe and effective introduction of the recommendations, an Implementation Working Group should be established with representation from the wider healthcare system in addition to relevant healthcare professionals. This was due to concerns raised around the logistical implementation of the recommendations which may delay treatment for those that need it.”

    Source location

    Response from Medicines and Healthcare products Regulatory Agency
    Page 2 · response
    Published 24 February 2023

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Mohammad Ismaeel Ashraf · 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

    Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

    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 a process for immediately communicating safety recommendations to affected parties

    Wider context from the report

    “5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. I am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem. ”

    Source location

    Mohammad Ismaeel Ashraf · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cambridgeshire and Peterborough

    AI-generated summary

    RICHARD THOMAS DAVIES · 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

    Richard Thomas Davies was killed by a police firearms officer during an incident on 21 October 2015 after he threatened his children and fired a homemade firearm at armed police officers. The report raised concerns about the use of unbonded ammunition by the joint Bedfordshire, Cambridgeshire and Hertfordshire Armed Policing Unit, including the absence of safeguards against excessive injury from bullet fragmentation and inadequate records of ammunition decisions.

    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 treat NPCC/CAST ammunition recommendations as superseding previous recommendations

    Wider context from the report

    “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces: • Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations. • Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies. • Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance. ”

    Source location

    RICHARD THOMAS DAVIES · 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 national firearms circulars at quarterly Firearms Steering Group meetings, record discussions and decisions, and update the STRA action log where necessary.

    Verbatim wording from the response

    “38. The STRA also includes an “action log” which is reviewed every three months at the FSG. If there are actions to be taken in response to a new circular, these will be discussed at the FSG and the STRA action log updated accordingly.”

    Source location

    2017-0325-Response-by-Bedfordshire-Police
    Page 7 · response
    Published 3 December 2017

    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 APU relies on NPCC and CAST to disseminate ammunition-evaluation guidance and clarify whether new recommendations supersede earlier ones.

    Verbatim wording from the response

    “45. The BCH APU is reliant on the NPCC and/or CAST to disseminate to local forces any guidance they produce on the evaluation of ammunition, and making clear whether any recommendations supersede or are to be read in conjunction with previous recommendations. All national circulars are now kept on the “POLKA” system, which is accessible to firearms departments throughout the country.”

    Source location

    2017-0325-Response-by-Bedfordshire-Police
    Page 8 · response
    Published 3 December 2017

    Open published response
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Data last updated 7 September 2026