PFD report

DARREN ROBERT DICKSON · Prevention of Future Deaths report

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Issued 16 Mar 2026•Cumbria

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in 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.

Report evidence summary

Concerns raised1

  1. Failure to retain and prevent destruction of supervision records
    Part of recurring concern: Failure to retain safety-critical source records and evidence
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.2

  1. Action

    Strengthen the Clinical Supervision Policy to prohibit disposal or destruction of records before three years and link to the national Records Management Code of Practice.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
  2. Action

    Issue a Trust-wide Policy Alert highlighting the coroner’s concern and the Clinical Supervision Policy amendment.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The existing policy already required clinical supervision records to be retained for at least three years; the destruction occurred outside expected policy guidance.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 retain and prevent destruction of supervision records

Wider context from the report

“I had evidence that Mr Dickson’s supervision records were being overwritten and the full nature of those records could not accurately be ascertained. Following Mr Dickson’s death, those supervision records were destroyed and were not available to me at the inquest. I heard evidence, and was provided with an updated policy, addressing the issues concerning overwriting of supervision records. I was therefore satisfied that the issues concerning overwriting of records has been addressed. I was not provided with sufficient evidence to allay my concern about the retention and the non-destruction of records and considered that the trust’s policy did not address the issue about destruction of records. I was therefore given insufficient reassurance that this specific concern is being addressed. ”

Is this part of a recurring concern?

Yes — Failure to retain safety-critical source records and evidence.

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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

Strengthen the Clinical Supervision Policy to prohibit disposal or destruction of records before three years and link to the national Records Management Code of Practice.

Verbatim wording from the response

“In addition, in response to HM Coroner's concern, the Trust has taken steps to further strengthen the relevant section of the Clinical Supervision Policy (enclosed). Section”

Source location

2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
Page 1 · response
Published 18 March 2026

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 a Trust-wide Policy Alert highlighting the coroner’s concern and the Clinical Supervision Policy amendment.

Verbatim wording from the response

“To bring this update to the attention of all staff, the Trust have also issued a Trust-wide Policy Alert, via email on 27th April 26, also enclosed. This alert summarised HM Coroner's concern from this case and highlighted the policy amendment.”

Source location

2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
Page 2 · response
Published 18 March 2026

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 existing policy already required clinical supervision records to be retained for at least three years; the destruction occurred outside expected policy guidance.

Verbatim wording from the response

“HM Coroner remained concerned, following the inquest, about the retention and the non-destruction of records and considered that the Trust’s policy did not suitably address this.”

Source location

2026-0150 - Response from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
Page 1 · response
Published 18 March 2026

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

Official responses located
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Data last updated 7 September 2026