Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
87match
Joan Knight
The mortality review was completed incorrectly, containing contradictory terms about whether the death was avoidable, which raises concerns about the accuracy of these reviews and inadequate learning from cases.
Matched on
terms: mortality, review
PFD report
73match
Michael Newell
The coroner identified a lack of awareness among A&E and surgical staff regarding the impact of decompensated liver failure on clinical management and insufficient knowledge of early hypovolaemia signs and treatment. Additional concerns included inadequate consultant input for complex cases and issues affecting the mortality review process.
Matched on
terms: mortality, review
PFD report
73match
Billy Longshaw
The Trust did not conduct a detailed investigation into Mr Longshaw's care, and its internal review was flawed, missing opportunities to consider issues related to patients with learning disabilities. Concerns were also raised about the adequacy of education for medical professionals on the practical application of the Mental Capacity Act 2005.
Matched on
terms: flawed, review
Inquiry recommendation
73match
38 - Improve perinatal mortality recording
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems...
Matched on
terms: mortality, review
CQC action
73match
Poole Hospital
Develop an action plan to capture the various strands of the work to develop an effective mortality and morbidity programme and to learn from the death or failings in care of patients. This should include bringing consistency, use of the structured judgement review, the standardisation of mortality and morbidity meetings and how they take place. It will need...
Matched on
terms: mortality, review
CQC action
69match
Kidderminster Hospital and Treatment Centre
The trust must ensure that all assigned mortality reviews are completed within the 30-day target.
Matched on
terms: mortality, review
CQC action
69match
The Christie Main Site
The trust must ensure that serious incidents and mortality reviews are investigated in a timely manner and learning is shared across the organisation as required.
Matched on
terms: mortality, review
CQC action
69match
North Tyneside General Hospital
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Matched on
terms: mortality, review
CQC action
69match
Berwick Infirmary
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Matched on
terms: mortality, review
CQC action
69match
Alnwick Infirmary
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Matched on
terms: mortality, review
PFD report
65match
David Tighe
The Trust lacked a specific Ryles tube policy, leading to inadequate guidance for clinicians and missing records of repeat position checks. Furthermore, a narrowly focused review of the death overlooked critical issues like missing clinical observations and Ryles tube checks.
Matched on
terms: review
PFD report
65match
Evie Muir
Hospital reviews into unusual cardiac deaths are not widely shared with all relevant clinicians, including rheumatology specialists, limiting the understanding of a patient's full clinical picture. There is also a need for adequate assessment of rheumatological risks, such as vasculitis, in cardiac patients with specific indicators.
Matched on
terms: review
PFD report
65match
Lacey Heath – Prevention of future deaths report
The coroner identified financial barriers to Ms Heath accessing recommended at-home anticoagulation monitoring, which prevented her from achieving a therapeutic INR. Concerns also included the absence of a funding application, inadequate medical record-keeping, and insufficient specialist review.
Matched on
terms: review
CQC action
65match
Clatterbridge Hospital
The trust should ensure that mortality reviews are undertaken in a timely way.
Matched on
terms: mortality, review
CQC action
65match
Whipps Cross University Hospital
The service should consider recording planned actions and timeframes for all Perinatal Mortality Reviews Summary Reports, serious incident reviews and Risk register reports.
Matched on
terms: mortality, review
CQC action
64match
North Middlesex University Hospital
The service must contribute to strengthening governance processes by supporting the timely completion of safety incident reviews, mortality reviews and complaints. The service must also ensure assurance checks are completed robustly and where needed improvements take place.
Matched on
terms: mortality, review
Committee recommendation
62match
#3 - Commission a multilateral development review to report on supported organisations' performance by 2026.
The Government should commission a multilateral development review to consider and report on the performance of the organisations it supports, before the end of 2026. (Recommendation, Paragraph 13)
Matched on
terms: review
Committee recommendation
62match
#2 - Multilateral development review urgently needed for understanding ODA commitments and performance.
A multilateral development review is urgently needed to underpin the change in proportion of ODA spent through this channel. The Government needs a clear understanding of its current commitments and the performance of multilateral organisations it supports. (Conclusion, Paragraph 12)
Matched on
terms: review
PFD report
61match
Connor Smith
Concerns were raised about the quality of the PPO's investigation, specifically regarding inaccurate attendance records at a segregation review hearing. Such errors could impede the learning of lessons from similar cases.
Matched on
terms: review
PFD report
61match
Thomas Jackson
Concerns included poor record keeping, inadequate conduct of multi-disciplinary team meetings, and staff lack of awareness about Clozapine's significance and side-effects. The Serious Incident Review process also contained significant inaccuracies.
Matched on
terms: review
PFD report
61match
Norma Lockton
Gaps in care planning for skin integrity and mobility, insufficient documented repositioning, and a failure to recognise deteriorating health led to delayed medical assistance. Additionally, there was a lack of robust management review following the death.
Matched on
terms: review
PFD report
61match
Lorraine Parker
The coroner noted deficiencies in Royal Berkshire Hospital's death investigation process, including delayed morbidity meetings, poor structured judgement reviews, and unreliable record systems. Concerns were also raised about the trust's management of a specific surgeon.
Matched on
terms: review
PFD report
61match
Karl Dunstan
The coroner identified that the investigation of a pulmonary embolism did not follow NICE guidance, and a CT pulmonary angiogram was rejected without a D-dimer test being completed. An urgent review of the hospital's relevant policy and procedure is needed.
Matched on
terms: review
PPO recommendation
61match
The Serious Incident Review Group of Manx Care
The Serious Incident Review Group of Manx Care should always complete an investigation following a death in custody.
Matched on
terms: review
CQC action
61match
The York Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Matched on
terms: review
CQC action
61match
Scarborough Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Matched on
terms: review
CQC action
60match
Stamford & Rutland Hospital
The service must ensure mortality and morbidity is reviewed regularly and incorporated into the governance of the service.
Matched on
terms: mortality, review
PFD report
57match
Wynter Andrews
The coroner noted inadequate initial critical analysis of deaths, risking missed learning opportunities. The report also highlights an unsafe culture within Midwifery Services, including unaddressed staff safety concerns, poor risk management, and insufficient clinical oversight.
Matched on
classifier match
PFD report
57match
Renate Mark
The coroner noted an internal investigation was flawed due to an incorrect report of a witnessed fall. Concerns were also raised regarding the observation of multiple high falls risk patients by a single staff member and a misunderstanding of falls observation terms.
Matched on
terms: flawed
PFD report
57match
Matthew Goldsmith
Abnormal findings on three separate CT scans were not reported by reviewing radiologists. Additionally, Barking Havering & Redbridge NHS Trust does not have a peer review system for radiology cases, as recommended by the Royal College of Radiologists.
Matched on
terms: review
PFD report
57match
Malik Bunton
Insufficient inquiry into a prior incident limited the RAF's suicide risk assessment for Mr Bunton. The coroner also noted weaknesses in the clinical care review process and significant delays in evidence gathering for subsequent investigations.
Matched on
terms: review
Inquiry recommendation
57match
11 - Medical examiners
i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a one-page document setting out all the steps to be taken by a medical examiner when dealing with the death of a neonate. ii. The revised SUDIC guidelines (see Recommendation 8 above) should be set out within the good practice guidelines for medical examiners, not...
Matched on
terms: review
Inquiry recommendation
57match
8 - Sudden Unexpected Death in Infancy and Childhood (SUDIC)
i. NHS England must: a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left hospital. b. Direct all Trusts that they must, within seven days, draw this information to the attention of all relevant staff and the Board. ii. DHSC must complete...
Matched on
terms: review
Inquiry recommendation
57match
R3 - Paediatric pathology in unexpected child deaths
We recommend that the provision of paediatric pathology services be reviewed with a view to ensuring that such services be engaged in every case in which the death of a child is unexpected or clinically unaccountable, whether the post mortem examination is ordered by a Coroner or in routine hospital practice (para 4.2.16)
Matched on
terms: review
Committee recommendation
57match
#42 - 2nd Report - Human Rights of Children in the Social Care System in England
We have heard some concerns about the varying quality of reviews of deaths of children in care. The government should investigate these concerns to ensure that safeguarding partners understand their role in notifying relevant authorities of children’s deaths, and that reviews are undertaken where appropriate to investigate causes of death and to take appropriate action when shortcomings are...
Matched on
terms: review
CQC action
57match
Sunderland Royal Hospital
The trust must implement an effective system to learn from deaths which ensures deaths are appropriately and consistently screened, further review is undertaken where required and lessons learnt are effectively identified and shared with teams.
Matched on
terms: review
CQC action
57match
South Tyneside District Hospital
The trust must implement an effective system to learn from deaths which ensures deaths are appropriately and consistently screened, further review is undertaken where required and lessons learnt are effectively identified and shared with teams.
Matched on
terms: review
PFD report
53match
Harold Wonfor
The coroner noted inadequate, incomplete, or unenforced falls risk assessments led to five patient deaths on a ward, with policies and procedures for falls prevention being insufficient, especially for vulnerable patients, and lacking adequate monitoring and enforcement.
Matched on
classifier match
PFD report
53match
Henry Honour
The coroner noted multiple deaths on a hospital ward caused by falls, citing inadequate, incomplete, or unenforced falls risk assessments. Specific issues included perfunctory initial assessments, inappropriate bedrail use, and a lack of updated assessments or protective measures after a fall.
Matched on
classifier match
PFD report
53match
George Elliott
The coroner identified that the Patient Safety Investigation (PSI) report following Mr. Elliott's death overlooked obvious failings in his care, specifically regarding inadequate falls risk assessments and their management. This resulted in missed opportunities for the Trust to learn and enhance patient safety.
Matched on
classifier match
PFD report
53match
Drew Howe
The Trust's investigation into Mr Howe's death did not fully consider his mental health service contacts, lacked critical analysis, and omitted the patient's perspective on access, thus limiting learning opportunities.
Matched on
classifier match
PFD report
53match
Francis Barnes
The coroner raises concerns about the Oxford Trust's approach to learning from deaths, noting a lack of investigation, no recorded meeting minutes, and an absence of proposed changes following Mr Barnes' death. The trust also did not cooperate with other hospitals for a joint investigation.
Matched on
classifier match
PFD report
53match
Charlie Millers
The coroner identified a lack of independent investigations for deaths of patients detained under the Mental Health Act, which hinders effective oversight and learning. Current investigations are also ineffective due to a lack of trained investigators or insufficient understanding of complex health processes.
Matched on
classifier match
CQC action
53match
West Suffolk Hospital
The trust should consider improving the quality of perinatal mortality and morbidity meeting minutes.
Matched on
terms: mortality
Inquiry recommendation
52match
F105 - Transparency use and sharing of information
Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
Matched on
terms: mortality
Inquiry recommendation
52match
40 - Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning the occasional need for inquests in individual cases, including deaths following neonatal transfer. Action: the Department of Health.
Matched on
terms: review
Inquiry recommendation
52match
39 - Implement medical examiner system
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and...
Matched on
terms: review
Scottish FAI
52match
Derek Adam
In the light of all this I would strongly recommend that the Crown and the prison authorities enter into arrangements or protocols to ensure that, following a death in prison, all relevant CCTV footage is urgently identified, recovered and preserved in the hands of the Crown, such that should any party to the subsequent inquiry, or the Court,...
Matched on
terms: review
Committee recommendation
52match
#20 - Fifth Report - The treatment of autistic people and people with learning disabilities
We therefore recommend that the Government and NHS England & Improvement bring forward the necessary financial and workforce resources required to mandate the independent review of the deaths of all autistic people and people with learning disabilities in inpatient and community settings, and ensure there is a structured way to make sure any learning that emerges is disseminated...
Matched on
terms: review
Committee recommendation
52match
#19 - Fifth Report - The treatment of autistic people and people with learning disabilities
In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into such deaths. Of even greater concern is that in some cases, the poor treatment of autistic people and...
Matched on
terms: review