Recurring concern

Unreliable gathering of witness evidence for formal investigations

First to latest report 29 May 2014 — 6 Feb 2026

Reports that mention this concern
17
Times this concern has been raised
19
Stated actions linked to this concern
34

What this concern includes

Includes failures to identify relevant witnesses and obtain, document or provide their statements or accounts in time for formal coronial, inquest, service, disciplinary, prosecution or comparable safety investigations.

What is not included
  • Excludes general investigation delays or incomplete investigations where no witness-evidence gathering failure is identified.
  • Excludes disclosure failures occurring after witness statements or accounts have been reliably obtained, unless the assertion also concerns obtaining the witness evidence itself.
  • Excludes failures to obtain non-witness documentary, digital or physical evidence unless the assertion also concerns the gathering of witness statements or accounts.
  • Excludes ordinary clinical, care or employment documentation failures that are not part of gathering evidence for a formal investigation or proceeding.

Reports and published responses 17 reports

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

  1. East London

    AI-generated summary

    Mansoor Zaman · 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

    Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to 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

    Patient safety investigations failing to seek treating staff recollections

    Wider context from the report

    “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff. ”

    Source location

    Mansoor Zaman · 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

    Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.

    Verbatim wording from the response

    “33. I understand it is frustrating that recollections of all staff are not always sought in PSII’s nor the findings communicated to all staff. Unfortunately, it is sometimes a balance of trying to obtain all clinician accounts (due to things such as sick leave) versus timely completion of the investigation. The same applies to feedback sessions. Though, to mitigate these issues, when staff are unable to attend feedback sessions they are routinely provided with a copy of the final report via email and asked to comment on it.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 7 · response
    Published 12 February 2026

    Open published response

  2. North Yorkshire and York

    AI-generated summary

    Malik BUNTON · 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

    Malik Bunton was found suspended from a ligature on 17 July 2023, and his death was confirmed at the scene. The inquest concluded that he died as a result of suicide, following earlier incidents involving suicidal intent and self-harm concerns. The principal concerns related to insufficient inquiry into an earlier incident, weaknesses in the Defence Medical Service Clinical Care Review process, and delays or obstructions in gathering important evidence.

    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 an account from a key hospital-attending colleague

    Wider context from the report

    “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were – - The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process. - The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest. - The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide. - Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death. - The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned. ”

    Source location

    Malik BUNTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays and obstructions in gathering evidence from key witnesses

    Wider context from the report

    “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were – - The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process. - The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest. - The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide. - Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death. - The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned. ”

    Source location

    Malik BUNTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in providing key witness statements to the Service Inquiry panel

    Wider context from the report

    “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were – - The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process. - The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest. - The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide. - Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death. - The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned. ”

    Source location

    Malik BUNTON · 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

    Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.

    Verbatim wording from the response

    “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.”

    Source location

    Response from Ministry of Defence
    Page 2 · response
    Published 20 October 2025

    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

    Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.

    Verbatim wording from the response

    “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.”

    Source location

    Response from Ministry of Defence
    Page 2 · response
    Published 20 October 2025

    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

    Issue further direction and guidance to avoid delays in providing statements to Service Inquiry panels.

    Verbatim wording from the response

    “Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.”

    Source location

    Response from Ministry of Defence
    Page 2 · response
    Published 20 October 2025

    Open published response

  3. North Yorkshire and York

    AI-generated summary

    Pamela Ann HONEYBONE · 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

    Pamela Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification 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 identify and preserve the accounts of staff directly involved in errors

    Wider context from the report

    “3. As a result of the delay at 2 above, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. ”

    Source location

    Pamela Ann HONEYBONE · 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

    Embed the Patient Safety Incident Response Framework within Trust processes.

    Verbatim wording from the response

    “We acknowledge that there was some delay in further investigations being carried out into the circumstances of the radiological error and this meant valuable witness evidence was not included. At the time of Mrs Honeybone’s death the Trust was in the early stages of implementing the Patient Safety Incident Response Framework (PSIRF). This framework is now embedded and if a similar incident occurred it would be likely that a hot debrief or after-”

    Source location

    Response from York and Scarborough NHS Trust
    Page 2 · response
    Published 29 September 2025

    Open published response

  4. North West Wales

    AI-generated summary

    Etta-Lili Stockwell-Parry · 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

    Etta-Lili Stockwell-Parry was born in poor condition on 3 July 2023 and died four days later after transfer for specialist neonatal care. The report identified missed opportunities to recognise static growth and fetal distress, inadequate monitoring and incomplete records during labour, and concerns that the neonatal investigation and sharing of learning were insufficiently thorough and contextualised.

    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 conduct sufficiently thorough neonatal investigations

    Wider context from the report

    “a. The neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta’s resuscitation, nor did they meet with them to understand what had occurred. The investigation was based on records alone. The records themselves, identified as part of the investigation, were often incomplete or included retrospective entries. Despite this, the investigator nor the panel involved considered speaking to or obtaining statements from crucial individuals. ”

    Source location

    Etta-Lili Stockwell-Parry · 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

    Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.

    Verbatim wording from the response

    “In relation to investigations, as you know this is an area of improvement I have prioritised. Last year, a new Integrated Concerns Policy was approved in June 2024 by the Board”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 22 May 2025

    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

    Implement a programme for investigating officers.

    Verbatim wording from the response

    “and implemented in September 2024. This new policy provides a single, integrated approach to incident, complaint and mortality reviews and investigations. The patient safety, complaint and mortality review teams are now working together as a more integrated hub to coordinate investigations, supported by a daily hub review meeting and a weekly clinical executive led meeting. A new programme for investigating officers has been implemented. The new policy also requires that all those involved in an incident are engaged in the process including receiving the sharing of information.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 22 May 2025

    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

    Direct that investigations across women’s and neonatal services use a single investigation officer.

    Verbatim wording from the response

    “Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 22 May 2025

    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

    Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.

    Verbatim wording from the response

    “Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 22 May 2025

    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

    Appoint a quality governance officer to neonatal services to provide specialist investigation and review capacity.

    Verbatim wording from the response

    “separate reviews were undertaken and then brought together). This will directly address quality and consistency, in line with how all other services operate. In addition, a directive has been issued that investigations across women’s services will use the framework and templates within the Integrated Concerns Policy (as opposed to the PMRT tool which was used for Etta’s case). The national tool will continue to be used however investigations will follow the established Health Board format. We have also appointed a new quality governance officer into neonatal services which will ensure access to local specialist skills and capacity for investigations and reviews.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 22 May 2025

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Matthew John LYNCH · 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

    Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.

    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 internal investigations to verify relevant witness information and clinical address records

    Wider context from the report

    “1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23. This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address. This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents. ”

    Source location

    Matthew John LYNCH · 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

    Provide Meet and Greet workers in community mental health team receptions to verify demographic, contact and accommodation information.

    Verbatim wording from the response

    “The review also found the process for updating and tracking address changes was not robust enough. To strengthen this process as referenced in the report, the team has implemented a “meet and greet” role to improve the accuracy of address updates and ensure better coordination. I will go into more detail around this point under point three.”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 6 March 2025

    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

    Remind clinical staff to record address and contact-number changes on the service-user demographic record in Rio.

    Verbatim wording from the response

    “We have also written to all clinical staff to remind them that if they are notified of a change of address (or contact number) that this is recorded on the service user demographic information in Rio, the electronic patient record, which updates the “front page” and not just in the “progress notes”.”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 6 March 2025

    Open published response

  6. North Wales (East and Central)

    AI-generated summary

    Paul Anthony Roberts · 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

    Paul Anthony Roberts took an overdose and inflicted multiple stab wounds in February 2023, after which he received no further mental health support. On 14 August 2023, he attended an emergency department because of deteriorating mental health, but psychiatric assessment was delayed and he left before it took place; he subsequently harmed himself and died on 15 August 2023 from a knife injury to the heart. The substantive concerns were failures in mental health referral and emergency-department care, insufficient accountability for staff actions or omissions, and delays in implementing identified safety measures.

    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 involve responsible staff in investigations of care failings

    Wider context from the report

    “An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED). Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place. My concerns are therefore as follows : 1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients. 2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients. ”

    Source location

    Paul Anthony Roberts · 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

    Introduce the new investigation template directing investigators to involve care staff and escalate concerns about care and treatment to managers.

    Verbatim wording from the response

    “As part of the new policy, there is new guidance, training and templates. The new template includes clear guidance for the investigator that directs them to include staff immediately involved in the care and treatment. This will ensure that staff delivering care are active contributors to learning investigations moving forward; it will also prompt the escalation of concerns about care and treatment to the managers of staff to ensure that any actions or omissions are addressed with staff appropriately. This template will be in use from 15 September 2024 as part of the new policy implementation.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 31 July 2024

    Open published response

  7. Inner South London

    AI-generated summary

    Daniel John O’Sullivan · 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

    Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.

    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 Serious Incident Investigations to investigate missing records and interview relevant witnesses

    Wider context from the report

    “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight. i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life. ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII. iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII. I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion. The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2. I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others. ”

    Source location

    Daniel John O’Sullivan · 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

    Accredit the serious incident review process through SIRAN, revising policies, templates and review arrangements to meet best practice.

    Verbatim wording from the response

    “At the beginning of 2020, the Trust sought to incorporate best practice in its management of serious incidents, which would result in improvement and effectiveness of the process and evidenced through Accreditation. Following several months of readiness activity including auditing and self-evaluation, workshops with Divisional representatives, implementation of agreed actions, revision of templates and redrafting of our policy, we succeeded through SIRAN. At the time of the changes, the Trust also introduced a forum to support reviewers/investigators of serious incidents to enhance understanding of the Root Cause Analysis (RCA) process.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 6 · response
    Published 25 October 2022

    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

    Provide RCA methodology training to staff and establish a forum supporting serious-incident reviewers and investigators.

    Verbatim wording from the response

    “At the beginning of 2020, the Trust sought to incorporate best practice in its management of serious incidents, which would result in improvement and effectiveness of the process and evidenced through Accreditation. Following several months of readiness activity including auditing and self-evaluation, workshops with Divisional representatives, implementation of agreed actions, revision of templates and redrafting of our policy, we succeeded through SIRAN. At the time of the changes, the Trust also introduced a forum to support reviewers/investigators of serious incidents to enhance understanding of the Root Cause Analysis (RCA) process.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 6 · response
    Published 25 October 2022

    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

    Create a dedicated serious incident review post in the incident division.

    Verbatim wording from the response

    “On the specific issue of skills and competency to undertake reviews/investigations, 88 members of staff have been trained in RCA methodology in the last 2 years (since 2020). This methodology equips reviewers with the skill to probe and draw out care and service delivery problems and guides them to elicit lessons. In addition, the Division in which the incident occurred now has a dedicated serious incident review post, offering additional skills and support in this process.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 6 · response
    Published 25 October 2022

    Open published response

  8. West Yorkshire Eastern

    AI-generated summary

    John Francis Heffron · 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

    John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.

    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 timely and adequate evidence during serious incident investigations

    Wider context from the report

    “(7) The Trust saw the need to initiate a “Serious Incident Investigation” but allocated this work to a person (i) present in the ED at the time of the incident, and thus not independent of the events being examined (ii) who had not been trained in such investigations save for a one-day course some five years previously and had never undertaken one of this nature before (iii) who spoke to the staff involved during the shift on the night of the incident, only when time permitted, alongside their other work. No written statements were obtained. In consequence, the precise chronology of events is unclear (iv) no context was provided which may have enabled an assessment of the workload or staffing levels in the ED at the material time For these reasons the inquest felt unable to rely upon the conclusions reached in the Serious Incident Investigation Report ”

    Source location

    John Francis Heffron · 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

    Provide the Emergency Department senior nursing team with a memory-capture tool to promote prompt, consistent incident recording and formalise evidence gathering.

    Verbatim wording from the response

    “In relation to your observations regarding the chronology of events it is noted that the incident summary in the investigation report does contain an outline chronology of events. It is acknowledged that it would have been helpful if this had contained more detail in regard to the time of the doctor’s attendance and if the report had been supported by notes of discussion with relevant staff. The Trust’s Investigation Procedure includes a range of tools and templates to assist staff when conducting investigations and whilst use of these is actively encouraged, it is not mandated. In response to the specific concerns raised about the investigation of this incident, the Trust has provided the ED senior nursing team with a memory capture tool to promote prompt and consistent recording of staff involvement in incidents and to formalise the evidence gathering stage of the investigation.”

    Source location

    Response from The Leeds Teaching Hospital
    Page 5 · response
    Published 3 October 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

    The Trust disputes that CPR was delayed for 15 minutes, stating that it began within 30 to 60 seconds of the patient being found.

    Verbatim wording from the response

    “(1) The Trust acknowledges that there was a delay in CPR being commenced after the patient had been found in an unresponsive condition and there were discrepancies in the evidence for the inquest about timings. However, the senior sister stands by the account that she gave in court i.e., that she had been contacted at 01.15am, after the doctor had been approached, and that she attended immediately after the call to her, by which time CPR was being undertaken. In her statement for the inquest, she explained that her discussions with the relevant team members afterwards indicated that CPR had been started within 30 to 60 seconds of the patient being found. The Trust understands that it was Dr Binbay’s recollection that she had been contacted at 01.30am however this was not supported by other staff members.”

    Source location

    Response from The Leeds Teaching Hospital
    Page 2 · response
    Published 3 October 2022

    Open published response

  9. Nottinghamshire

    AI-generated summary

    Jade Michelle Hart · 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

    Jade Michelle Hart died on 9 July 2018 after giving birth, following a uterine inversion caused by inappropriate management of the third stage of labour. She suffered massive uterine haemorrhage and multiple cardiac arrests, with delayed recognition and management of the bleeding, and the inquest concluded that her death was contributed to by neglect. The report raised concerns about the Trust’s serious incident investigation and insufficient support for newly appointed obstetric consultants.

    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 timely written accounts and interviews from key staff in serious incident investigations

    Wider context from the report

    “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows: • It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report • It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved • The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept. All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view. Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report. At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning. If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change. ”

    Source location

    Jade Michelle Hart · 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

    Use a memory-capture document in DATIX alongside immediate interviews and written statements, and reinforce its use across teams.

    Verbatim wording from the response

    “Furthermore, the Trust recognises how vital it is to document factual accounts of events at the earliest opportunity and that this should be done without delay. When an incident occurs within the organisation, this is immediately scoped which includes requesting a recollection of the event from all staff involved in the incident. To support this process, a memory capture document (please see attached) was developed and is accessible on the Trust’s Incident Reporting System (DATIX) for ease of access and is utilised in addition to undertaking initial interviews and obtaining factual accounts in the form of written statements.”

    Source location

    Response from NHS Doncaster and Bassetlaw Teaching Hospitals
    Page 3 · response
    Published 28 September 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

    HSIB could not support the requested investigation because its northern branch had not yet been established and operations were limited to southern England.

    Verbatim wording from the response

    “I can assure you that incidents of this kind are no longer investigated by the Trust and are now escalated to the Healthcare Safety Investigation Branch (HSIB) to carry out the investigation. As stated in the evidence provided in the inquest by ████████, Executive Medical Director, the Trust did approach HSIB shortly after the incident to request their involvement. However, they were unable to support us at that time, as their northern branch had not been established and they were only operating in the South of England.”

    Source location

    Response from NHS Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 28 September 2022

    Open published response

  10. Manchester City

    AI-generated summary

    Darren John Lawrence · 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 John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

    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 SUI investigation to obtain evidence from an important witness

    Wider context from the report

    “h. The CMHT Responsible Clinician was an important witness but the GMMH SUI investigation did not obtain a statement from him and those carrying out the investigation failed to recognise the significance of this. Nor was this identified in the overview of the report before it was signed off. This meant all the lessons for future care and planning were not learnt. The court has received evidence about the same issue in other inquests involving deaths of GMMH patients and is a repeated matter of concern ”

    Source location

    Darren John Lawrence · 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 Trust considers interviewing the Responsible Clinician would not have changed the internal review’s findings.

    Verbatim wording from the response

    “The CMHT Responsible Clinician did not see Mr Lawrence during the timeframe being examined during the GMMH internal review of the care and treatment delivered to Mr Lawrence prior to his death. Mr Lawrence was seen by medical staff, on one occasion at his home address. The medical staff discussed the case with the CMHT RC and the RC gave advice which was acted upon.”

    Source location

    2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 5 · response
    Published 21 October 2021

    Open published response

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