Recurring concern

Unreliable death notification and verification records

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First reported 2 Mar 2020•Latest report 5 May 2021

Definition

What this concern includes

Includes failures to accurately or completely complete, review or maintain forms and records used to verify or notify deaths, including incorrect expected-death classifications and omission of material circumstances or problems leading to death.

Not included

  • Excludes coronial autopsy, inquest disclosure and death-investigation processes where the deficiency is not the completion or reliability of a death notification or verification record.
  • Excludes general clinical, care or incident records unless they are specifically used for death notification or verification.
  • Excludes failures to act on accurate death notification or verification information when the record itself was completed reliably.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2020–2021

First to latest report issue date

Stated actions
0

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.

Care Quality Commission1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
General Medical Council1
NHS England1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Sheffield Teaching Hospitals NHS Foundation 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.

  1. South Yorkshire (Western)

    AI-generated summary

    Laura Booth · 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

    Laura Booth died at the Royal Hallamshire Hospital on 19 October 2016 after becoming unwell during an admission for a routine procedure. The inquest found that inadequate management of her nutritional needs led to malnutrition, which contributed to her death, and that clinical decisions about her care were made without properly involving her or her parents under the Mental Capacity Act. The report also raised concerns about staff understanding and application of the Mental Capacity Act and the use of Laura’s hospital passport.

    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 complete verification of death forms

    Wider context from the report

    “(9) I remain concerned that all staff treating Laura have expressed the view that they did not expect Laura to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death. I would therefore challenge the Trust to consider whether there is a need to reflect on the completion of these forms and their importance and likewise whether there is a need to reflect on presumptions made about an individual's underlying health conditions when completing verification of death forms. ”

    Source location

    Laura Booth · Prevention of Future Deaths report
    Page 4 · 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 death was expected after the decision to provide best supportive care, so the verification-of-death documentation was accurate.

    Verbatim wording from the response

    “In addition to these specific actions, you also highlighted concerns about the fact that the verification of death forms Laura’s death as being expected, when this was not reflected in the views expressed by the staff caring for her. As requested, Dr ████████, Clinical Lead for Infectious Diseases, has reviewed the verification of death process in this case and I attach a copy of his report for your information. Dr ████████ notes that, whilst at the start of Laura’s admission her death was not expected, this picture changed during her stay. On the last day of her life, Laura had a respiratory arrest from which she was successfully resuscitated, after which the decision was collectively made between the clinicians and Laura’s parents to move to best supportive care and not pursue further active treatment, escalation or resuscitation attempts.”

    Source location

    2021-0137-Response-from-Northern-General-Hospital_Published
    Page 4 · response
    Published 5 May 2021

    Open published response

  2. North East Kent

    AI-generated summary

    HARRY RICHFORD · 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

    Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

    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

    Inaccurate and incomplete child death notification forms

    Wider context from the report

    “Concern 17 The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this. ”

    Source location

    HARRY RICHFORD · Prevention of Future Deaths report
    Page 19 · 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 Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

    Verbatim wording from the response

    “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 October 2022

    Open published response
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Data last updated 7 September 2026