PFD report

Kenneth Foster · Prevention of Future Deaths report

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Issued 12 May 2025•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

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 raised1

  1. Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
    Part of recurring concern: Inadequate safety incident investigations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
  2. Action

    Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
  3. Action

    Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice

Wider context from the report

“A. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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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

Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.

Verbatim wording from the response

“As part of the learning from this PFD, the Whipps Cross Hospital Senior Leadership Team will ensure that families are contacted as part of the Patient Safety Incident Review Meeting (PSIRM) process to ensure that a more robust review is undertaken. Taking account of family concerns should be a key aspect to inform decision making around the level of investigation required. This action will also ensure reviews include the views of the patient’s family, in line with Patient Safety Incident Response Framework (PSIRF) compassionate engagement principles.”

Source location

2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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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

Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.

Verbatim wording from the response

“Since December 2024, at Whipps Cross Hospital, each new inquest opened is reported via the incident reporting system (Datix). The cases are presented at the Patient Safety Incident Response Meeting (PSIRM) and where a Mortality and Morbidity Meeting (M&M) has not yet been held, arrangements are made to expedite this process to inform decision making around the type of learning response required in accordance with the Patient Safety Incident Response Plan.”

Source location

2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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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

Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.

Verbatim wording from the response

“In order to gain additional assurance, the Trust has commissioned a review to be undertaken by a specialist within the North London Integrated Care Board and supported by NHSE to review”

Source location

2025-0231-Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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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

Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.

Verbatim wording from the response

“As such, under PSIRF, not all deaths will be investigated. This will include some which go to inquest. Decision-making regarding patient safety incident response should be documented by Trusts as part of a robust governance process. Where a specific learning response is not undertaken in relation to an incident discussed at inquest, the organisation should be able to explain why this was the case.”

Source location

2025-0231-Response from The Department of Health and Social Care
Page 1 · response
Published 21 May 2025

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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

Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.

Verbatim wording from the response

“While PSIRF represents a significant improvement to the way that the NHS responds to patient safety incidents, PSIRF does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient.”

Source location

2025-0231-Response from The Department of Health and Social Care
Page 1 · response
Published 21 May 2025

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Share the PFD and response with the Trust Safety Committee, NHSE, CQC, and NELICB.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.

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

Share the PFD and response with the Trust Safety Committee, NHSE, CQC, and NELICB.

Verbatim wording from the response

“The Prevention of Future Death report has been reviewed at Whipps Cross Hospital (WCH) Divisional and Hospital Boards to agree actions that will have an impact across the Barts Health group. The PFD and response has been shared at Trust Safety Committee, with National Health Service England (NHSE), the Care Quality Commission (CQC) and the North East London Integrated Care Board (NELICB).”

Source location

2025-0231-Response from Barts Health NHS Foundation Trust
Page 1 · response
Published 21 May 2025

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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