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First report 24 Sep 2021•Latest report 24 Sep 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Eastern)

    AI-generated summary

    Clay Daniel Wanckiewicz · 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

    Clay Daniel Wanckiewicz was born in very poor condition following failed forceps delivery and caesarean section complicated by a deeply impacted head, and died at 22 minutes of age from skull fractures. The principal concerns were confirmation bias, insufficiently open-minded assessment of the overall clinical picture, inadequate staff training and a continuing risk that similar situations could place mothers and babies at risk.

    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. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Staff reluctance to accept confirmation bias and alter practices

    Wider context from the report

    “(1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prioritise relevant staff for confirmation bias training

    Wider context from the report

    “(1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of all staff to consider and digest the Newsletters

    Wider context from the report

    “(1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to understand confirmation bias

    Wider context from the report

    “(1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Delayed completion of confirmation bias training by staff

    Wider context from the report

    “(1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026