Samantha Jane ANGEL · Prevention of Future Deaths report

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Issued 9 May 2024•Hampshire, Portsmouth and Southampton

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
15

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to factor distress caused by publication into the timely conclusion of investigations
  2. Delays in resolving workplace behaviour investigations
  3. Failure to maintain confidentiality of circumstances leading to workplace allegations

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. Portsmouth Hospitals University NHS Trust

    Develop enhanced systems for recording, monitoring, prioritising, and reviewing HR cases.

  2. Portsmouth Hospitals University NHS Trust

    Conduct regular HR case reviews and monthly Professional Standards Committee oversight of case progress.

  3. Portsmouth Hospitals University NHS Trust

    Assess and revise HR policies and procedures to embed a fair and learning culture.

  4. Portsmouth Hospitals University NHS Trust

    Implement a Trust-wide communications and engagement plan reminding staff not to include or circulate personal identifiable incident data.

  5. Portsmouth Hospitals University NHS Trust

    Expand the Trust’s pool of trained investigators to improve hearing efficiency and effectiveness.

  6. Portsmouth Hospitals University NHS Trust

    Implement tailored training programmes, workshops, and awareness campaigns supporting a just and learning culture.

  7. Portsmouth Hospitals University NHS Trust

    Add a prominent DCIQ warning prohibiting personal identifiable data in incident descriptions and action fields.

  8. Portsmouth Hospitals University NHS Trust

    Appoint new HR leadership roles to support case oversight, staff welfare, and employee-relations management.

  9. Portsmouth Hospitals University NHS Trust

    Explore integrating or jointly procuring a case-management system with the Isle of Wight Trust.

  10. Portsmouth Hospitals University NHS Trust

    Provide refreshed training for managers using anonymised cases to improve investigation decisions and case management.

  11. Portsmouth Hospitals University NHS Trust

    Introduce a Protected Time Agreement and investigation protocol requiring wellbeing observation, support, escalation, documentation, and confidentiality.

  12. Portsmouth Hospitals University NHS Trust

    Provide investigation participants with wellbeing-service information and assign wellbeing contacts for investigation-duration check-ins.

  13. Portsmouth Hospitals University NHS Trust

    Develop safeguarding and workplace-equality training for HR advisers.

  14. Portsmouth Hospitals University NHS Trust

    Request Governance Leads to review incident-notification lists for accuracy.

  15. Portsmouth Hospitals University NHS Trust

    Establish reporting metrics and KPIs for HR casework.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Portsmouth Hospitals University NHS Trust

    Existing staff-record and spreadsheet resources are considered adequate to manage the HR caseload while enhanced recording and monitoring systems develop.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Portsmouth Hospitals University NHS Trust

    The cost of external investigators prevents their routine use, limiting reliance on them to urgent or serious cases.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Portsmouth Hospitals University NHS Trust

    Incident distribution lists include staff whose roles require visibility to review, investigate, understand and manage incidents.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to factor distress caused by publication into the timely conclusion of investigations

Wider context from the report

“3. The recognition that the distress caused to the deceased by the publication of the circumstances, should be a factor in accelerating a conclusion to an investigation, not just the consequences of any findings of an investigation if negative to the deceased. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in resolving workplace behaviour investigations

Wider context from the report

“1. The delay in resolving the investigation commissioned into the deceased behaviour at work. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain confidentiality of circumstances leading to workplace allegations

Wider context from the report

“2. The ease with which the circumstances leading to the allegation are made public amongst the deceased's' work colleagues and the consequences of that. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Develop enhanced systems for recording, monitoring, prioritising, and reviewing HR cases.

Verbatim wording from the response

“3. In the meantime, we are using our existing resources, namely the Electronic Staff Record and Excel, to manage our caseload effectively. At any given time, we handle 35-40 cases with the support of a proficient HR Advisory Team comprising 7 qualified professionals. In line with our commitment to enhancing our investigative processes, significant improvements are in development in the recording and monitoring of cases. These enhancements provide a comprehensive overview of our total casework, facilitating more efficient prioritisation and systematic review based on the length and complexity of each case. By refining our recording and monitoring systems, this enables us to strategically prioritise cases based on various factors, including their length, complexity, and urgency.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Conduct regular HR case reviews and monthly Professional Standards Committee oversight of case progress.

Verbatim wording from the response

“6. Regular reviews of cases are routinely conducted by our HR operational team and a monthly review of cases completed by our professional standards committee ensures ongoing oversight of case progress. Our letters which go out to employees during informal”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Assess and revise HR policies and procedures to embed a fair and learning culture.

Verbatim wording from the response

“5. In looking ahead to the future, our long-term vision includes a strategic and thorough assessment of our policies and processes to solidify and promote a culture centred on fairness and continuous learning. This involves a proactive and comprehensive review of all existing policies and procedures to ensure they align with the principles of a just and learning culture. Our plan encompasses a structured approach to embedding this culture throughout the organisation, focusing on fostering transparency, accountability, and a commitment to ongoing improvement. By revisiting and revising our policies, we aim to create a supportive and empowering work environment where employees feel encouraged to learn from experiences, share feedback openly, and contribute to a culture of continuous development.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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 Trust-wide communications and engagement plan reminding staff not to include or circulate personal identifiable incident data.

Verbatim wording from the response

“3. In partnership with the Trust Communications Team, we have also initiated a communications and engagement plan for all staff to remind them of the importance of not including PID, in the “description” and “actions taken” fields of any incident reported on DCIQ.”

Source location

Response from Portsmouth Hospitals
Page 4 · response
Published 14 May 2024

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

Expand the Trust’s pool of trained investigators to improve hearing efficiency and effectiveness.

Verbatim wording from the response

“7. Further enhancing our initiatives, we are developing a comprehensive training programme for our HR advisory team, specifically focusing on areas such as safeguarding and fostering equality in the workplace. To bolster our investigative capabilities, we are expanding our pool of trained investigators across the Trust, a move intended to enhance the efficiency and effectiveness of our hearing procedures. While external investigators are occasionally engaged for cases involving urgent or serious issues, the associated costs inhibit routine utilisation.”

Source location

Response from Portsmouth Hospitals
Page 3 · response
Published 14 May 2024

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 tailored training programmes, workshops, and awareness campaigns supporting a just and learning culture.

Verbatim wording from the response

“This long-term strategy involves the implementation of tailored training programmes, workshops, and awareness campaigns to reinforce the values and behaviours associated with a just and learning culture.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Add a prominent DCIQ warning prohibiting personal identifiable data in incident descriptions and action fields.

Verbatim wording from the response

“As a result of learning from this case, a new message has been added to the front page of the system that all reporters of incidents see when they log in:”

Source location

Response from Portsmouth Hospitals
Page 4 · response
Published 14 May 2024

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 new HR leadership roles to support case oversight, staff welfare, and employee-relations management.

Verbatim wording from the response

“1. We have refreshed the leadership within the HR Operational Team, appointing a new Head of Employee Relations and Inclusion to focus on providing methods to support our managers and their supporting HR staff to enable them to keep checking on cases and to ensure that staff welfare remains paramount. Concurrently, the new Head of Service, a senior role, collaborates with the team to establish reporting metrics and Key Performance Indicators (KPIs) for all HR case work.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Explore integrating or jointly procuring a case-management system with the Isle of Wight Trust.

Verbatim wording from the response

“2. We are utilising our partnership with the IOW Trust to explore the integration of their Case Management System or a separate joint Case Management System to enhance our investigative processes.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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 refreshed training for managers using anonymised cases to improve investigation decisions and case management.

Verbatim wording from the response

“4. The HR Advisory Team utilise the just culture approach and understand the critical importance of assessing the necessity for an investigation before a manager proceeds with that course of action, often highlighting the viability of informal actions or learning interventions as an appropriate alternative to a formal investigation. Ongoing efforts include providing refreshed training sessions for managers, utilising anonymised cases that underscore the significance of sound decision-making and adept case management.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Introduce a Protected Time Agreement and investigation protocol requiring wellbeing observation, support, escalation, documentation, and confidentiality.

Verbatim wording from the response

“8. The introduction of a Protected Time Agreement and Protocol for Investigating Officers underscores our commitment to prioritising the health and wellbeing of all parties involved in investigations. Notably, the Protocol outlines steps for immediate action to address signs of distress or wellbeing concerns during the investigation process. It is designed to establish a framework that ensures Investigating Officers have dedicated time to effectively conduct investigations, review documents, interview involved parties, and prepare reports in accordance with disciplinary and grievance processes. It also emphasises the importance of ensuring the wellbeing of all individuals involved in the investigation process. Included in the protocol are the following points:”

Source location

Response from Portsmouth Hospitals
Page 3 · response
Published 14 May 2024

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 investigation participants with wellbeing-service information and assign wellbeing contacts for investigation-duration check-ins.

Verbatim wording from the response

“6. Regular reviews of cases are routinely conducted by our HR operational team and a monthly review of cases completed by our professional standards committee ensures ongoing oversight of case progress. Our letters which go out to employees during informal”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Develop safeguarding and workplace-equality training for HR advisers.

Verbatim wording from the response

“7. Further enhancing our initiatives, we are developing a comprehensive training programme for our HR advisory team, specifically focusing on areas such as safeguarding and fostering equality in the workplace. To bolster our investigative capabilities, we are expanding our pool of trained investigators across the Trust, a move intended to enhance the efficiency and effectiveness of our hearing procedures. While external investigators are occasionally engaged for cases involving urgent or serious issues, the associated costs inhibit routine utilisation.”

Source location

Response from Portsmouth Hospitals
Page 3 · response
Published 14 May 2024

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

Request Governance Leads to review incident-notification lists for accuracy.

Verbatim wording from the response

“2. The distribution list for incident forms includes those members of staff who require visibility of the incident in their area of work or speciality to enable them—as part of their role and responsibilities—to review, investigate, have awareness of, and manage incidents. For example, the Accredited Security Management Specialist is notified in order that they can give specialist input and offer advice regarding any review/investigations related to violence and aggression.”

Source location

Response from Portsmouth Hospitals
Page 4 · response
Published 14 May 2024

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 reporting metrics and KPIs for HR casework.

Verbatim wording from the response

“1. We have refreshed the leadership within the HR Operational Team, appointing a new Head of Employee Relations and Inclusion to focus on providing methods to support our managers and their supporting HR staff to enable them to keep checking on cases and to ensure that staff welfare remains paramount. Concurrently, the new Head of Service, a senior role, collaborates with the team to establish reporting metrics and Key Performance Indicators (KPIs) for all HR case work.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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

Existing staff-record and spreadsheet resources are considered adequate to manage the HR caseload while enhanced recording and monitoring systems develop.

Verbatim wording from the response

“3. In the meantime, we are using our existing resources, namely the Electronic Staff Record and Excel, to manage our caseload effectively. At any given time, we handle 35-40 cases with the support of a proficient HR Advisory Team comprising 7 qualified professionals. In line with our commitment to enhancing our investigative processes, significant improvements are in development in the recording and monitoring of cases. These enhancements provide a comprehensive overview of our total casework, facilitating more efficient prioritisation and systematic review based on the length and complexity of each case. By refining our recording and monitoring systems, this enables us to strategically prioritise cases based on various factors, including their length, complexity, and urgency.”

Source location

Response from Portsmouth Hospitals
Page 2 · response
Published 14 May 2024

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 cost of external investigators prevents their routine use, limiting reliance on them to urgent or serious cases.

Verbatim wording from the response

“7. Further enhancing our initiatives, we are developing a comprehensive training programme for our HR advisory team, specifically focusing on areas such as safeguarding and fostering equality in the workplace. To bolster our investigative capabilities, we are expanding our pool of trained investigators across the Trust, a move intended to enhance the efficiency and effectiveness of our hearing procedures. While external investigators are occasionally engaged for cases involving urgent or serious issues, the associated costs inhibit routine utilisation.”

Source location

Response from Portsmouth Hospitals
Page 3 · response
Published 14 May 2024

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

Incident distribution lists include staff whose roles require visibility to review, investigate, understand and manage incidents.

Verbatim wording from the response

“2. The distribution list for incident forms includes those members of staff who require visibility of the incident in their area of work or speciality to enable them—as part of their role and responsibilities—to review, investigate, have awareness of, and manage incidents. For example, the Accredited Security Management Specialist is notified in order that they can give specialist input and offer advice regarding any review/investigations related to violence and aggression.”

Source location

Response from Portsmouth Hospitals
Page 4 · response
Published 14 May 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026