Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
14 inquiry recs
47 PFD reports
11 committee recs
3 HSSIB recs
20 CQC actions
5 PPO recs
13 IMB recs
4 IMB reports
3 Scottish FAIs
66 DHR recs
5 PHSO decisions
3 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(14)
11 — Medical examiners
Recommendation: 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 …
Gov response: It welcomes the introduction of medical examiners but said it should have happened 10 years earlier. I agree. We will set out further plans to strengthen their neonatal expertise following the inquiry’s recommendations when the …
Response Unclear
8 — Sudden Unexpected Death in Infancy and Childhood (SUDIC)
Recommendation: 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 …
Gov response: The inquiry says the sudden, unexpected death in infancy and childhood guidance must be updated. I agree. That is now underway.
Accepted
6 — Monitoring deaths in hospitals
Recommendation: i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor board-level …
Unknown
R3 — Paediatric pathology in unexpected child deaths
Recommendation: 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 …
Gov response: Recommendation 3. 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 …
Response Unclear
F278 — Death certification
Recommendation: It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or …
Gov response: Accepted. The Government intends to publish draft death certification regulations for medical examiners in England that will require that medical examiners obtain and consider information available about patient safety to inform their professional judgement as …
Accepted
F277 — Death certification
Recommendation: National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.
Gov response: Accepted. We intend to publish draft death certification regulations that states that the Chief Medical Officer of the Department of Health must issue guidance on how death certification forms are completed. This will include a …
Accepted
F105 — Transparency use and sharing of information
Recommendation: Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
Gov response: Accepted. As part of Professor Sir Bruce Keogh’s Review of the Quality and Safety of Care and Treatment Provided by 14 Hospital Trusts in England, NHS England provided detailed reports from the National Reporting and …
Accepted
40 — Extend medical examiners to stillbirths
Recommendation: 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 …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted in part
39 — Implement medical examiner system
Recommendation: 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 …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted in part
38 — Improve perinatal mortality recording
Recommendation: 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 …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
F279 — Death certification
Recommendation: So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient's case or treatment.
Gov response: Accepted. Existing guidance that is provided with medical certificates of cause of death states that death certification should be completed by a consultant or senior clinician, although this could be delegated to a junior doctor …
Accepted
F276 — Independent medical examiners
Recommendation: Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.
Gov response: Accepted. The Coroners and Justice Act 2009 requires the appointment of enough medical examiners, and the availability of sufficient funds and resources, to ensure the functions of medical examiners are discharged within the appointing area. …
Accepted
F275 — Independent medical examiners
Recommendation: It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
Gov response: Accepted in principle. The Government agrees that medical examiners must be independent of the deceased and their medical practitioner. This is because medical examiners need carry out independent scrutiny of the medical circumstances and cause …
Accepted in part
LAMI-5 — National Agency to conduct or oversee and publish serious child case reviews
Recommendation: The National Agency for Children and Families should, at their discretion, conduct serious case reviews (Part 8 reviews) or oversee the process if they decide to delegate this task to other agencies following the death or serious deliberate injury to …
Unknown
Prevention of Future Deaths reports(47)
John William Wright
Concerns: The hospital did not investigate the cause of a patient's fall as a Serious Untoward Incident, and appropriate electronic records were not made. It was also unclear if falls prevention training and recording protocols applied to all staff.
Overdue
Ann Bennett
Concerns: The coroner regarded the death as potentially avoidable and endorsed recommendations from a Trust investigation report. The report emphasised that the Trust must seriously address the issues detailed within its own recommendations.
Overdue
Nadine Thurman
Concerns: The coroner raised concerns regarding the psychiatric assessment of Mrs. Thurman, specifically that a caregiver was not permitted to contribute and the patient was asked in a suggestive manner if she was content to be seen alone.
Overdue
Janet Goodacre
Concerns: The coroner raised concerns about the Trust providing inaccurate and misleading investigation reports, which contained erroneous findings and incorrect root causes. There was also a failure to communicate the report's shortcomings or correct recognised errors before the inquest.
Response (University Hospitals of Leicester NHS Trust): • The Trust established a process for each Root Cause Analysis (RCA) investigation to have a named Chair who reviews the investigation's scope and ensures an adequate action plan is … (AI summary)
Responded
Connor Smith
Concerns: 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.
Response (Prisons Probation Ombudsman): • The Prisons and Probation Ombudsman (PPO) acknowledged an apparent minor factual inaccuracy in its report. • The PPO stated that it did not believe further specific action could be … (AI summary)
Response (HM Prison and Probation Service): • A notice was issued to senior managers who chair Segregation Review Boards. • The notice advised that documentation for meetings must not have names entered in advance and that … (AI summary)
Overdue
Angus West
Concerns: The coroner noted the non-retention of the placenta after a baby's death hindered the pathologist's investigation into potential causes like infection or umbilical cord issues. It was recommended that placentas be retained in similar circumstances.
Response (The Royal College of Midwives): • The Royal College of Midwives (RCM) stated its agreement with the coroner's recommendations to the NHS Trust. • The RCM indicated that best practice would involve retaining and safely … (AI summary)
Response (York Teaching Hospital): • The Trust shared the notification with its Clinical Director for Obstetrics and Gynaecology and the Risk Management team. • The Trust liaised with the Royal College of Obstetrics and … (AI summary)
Responded
Michael Newell
Concerns: 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.
Overdue
Harold Wonfor
Concerns: 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.
Response (Response East Kent NHS Trust): • The Trust continues work on timely and adequate falls risk assessments and monitors patient falls rates and harm monthly. • The Trust reviewed its Falls Risk Assessment and Care … (AI summary)
Responded
Henry Honour
Concerns: 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.
Overdue
Peter King
Concerns: The coroner noted that falls risk assessments were often inadequate, incomplete, or not enforced, and that interventions to prevent falls were either not recognised or not implemented. Specific concerns included poor documentation of precautions, lack of referrals, and unaddressed escalation of safety needs for an observable bed.
Response (East Kent NHS Trust): • The Trust reviewed its Falls Risk Assessment and Care Plan (FRACP) to incorporate National Institute Health and Care Excellence (NICE) guidance. • A quality improvement programme named "Fallstop" was … (AI summary)
Responded
Thomas Jackson
Concerns: 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.
Response (Department of Health and Social Care): • The issue of monitoring clozapine blood plasma levels has been logged for consideration by the NICE guideline surveillance team. • Concerns raised have been added to the MHRA’s adverse … (AI summary)
Overdue
Malcolm Shaw
Concerns: The coroner noted fundamental flaws in the Trust's original investigation into a patient's fall and a need for revised investigation training. There were also concerns about the lack of guidance for frontline staff on capturing evidence immediately after falls.
Response (Stockport NHS Trust): • The Trust confirmed a programme of investigation training had been developed and launched, including specific sessions on statement gathering and writing. • The Trust implemented a checklist in February … (AI summary)
Responded
Frank Stockton
Concerns: The coroner noted potential insufficient awareness among clinicians regarding the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy, taking Warfarin, or with impaired lung/heart function. There is also a concern that clinicians may not know that maintaining INR within target range does not fully avoid this risk.
Overdue
Gloria Mekins
Concerns: The coroner raised concerns regarding a Health Care Assistant's failure to provide first aid for choking, a delay in aid due to confusion over a DNA CPR order, and the care home's lack of internal investigation into the incident.
Response (Rossmere Park Care Centre): • The care home implemented a new system to notify staff of DNACPR notices, using blue butterflies on room doors and red notices in resident folders. • The care home … (AI summary)
Overdue
Gary Etherington
Concerns: The coroner noted professionals discounted symptoms without adequate investigation or addressing GP concerns, leading to discharge without psychiatric follow-up. The Root Cause Analysis subsequently failed to identify these care problems.
Response (Oxleas NHS Trust): • The Trust developed a Support Network Engagement Tool (SNET) and conducts monthly audits of care plans to promote family and carer involvement in assessments. • The Trust ensures primary … (AI summary)
Responded
Wynter Andrews
Concerns: 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.
Response (Nottingham University Hospitals NHS Trust): • The Trust stated that a newly formed Maternity Programme Oversight Committee, chaired by the Chief Executive Officer, would oversee the delivery of actions. • The Trust stated that the … (AI summary)
Responded
Eddie Coffey
Concerns: A gross failure in monitoring and managing foetal heart rate during labour was identified, which experts linked to the death. The coroner questioned if current training prevents recurrence, and noted concerns that 100 units may follow incorrect guidelines.
Response (Lister Hospital): • The Trust committed to ensuring future independent clinical opinions are obtained on a more formal basis with clear terms of reference. • A full-time fetal monitoring specialist midwife was … (AI summary)
Response (Dept. for Health and Social Care): • The Care Quality Commission (CQC) monitored improvements at the Trust, noting that 86% of midwives and 73% of medical staff had received additional training in fetal monitoring by October … (AI summary)
Responded
Norma Lockton
Concerns: 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.
Overdue
Betty Tadman
Concerns: The coroner noted a lack of consideration for potential fracture injury and absence of imaging following a fall, compounded by over-reliance on pain complaints from a patient with dementia. There was also no serious incident investigation by the Trust after the death.
Response (Medway Maritime Hospital): • The Trust has introduced a "front door" team of specialist nurses in the Emergency Department to assess elderly frail patients. • A system has been initiated to ensure post … (AI summary)
Responded
Billy Longshaw
Concerns: 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.
Overdue
Derek Holmes
Concerns: The coroner identified basic errors in the Root Cause Analysis investigation of a patient's fall, which limited learning and did not fully examine issues like call-bell functionality or delays in specialist advice. The initial 'moderate' harm grading of the fall was also not revisited, affecting the investigation's thoroughness.
Response (NHS Tameside and Glossop Integrated Care): • The Trust has revised its Safer Care Assurance Process to require all investigations to be reviewed and approved by an appropriate Matron for accuracy. • A revised safety checklist … (AI summary)
Responded
George Elliott
Concerns: 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.
Response (North Bristol NHS Trust): • The Trust acknowledged that the patient safety investigation into Mr Elliot's death missed key elements. • The Trust replaced its Falls Policy in December 2021, aligning it with NICE … (AI summary)
Responded
Drew Howe
Concerns: 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.
Response (Pennine Care NHS Foundation Trust): • The Trust has reviewed its Rapid Initial Review template and held a professionals meeting to consider Mr Howe's patient journey. • An objective Serious Incident Investigation has been commissioned … (AI summary)
Responded
Roger Southwick
Concerns: The coroner noted issues with the accurate completion of the Falls Risk Assessment and the lack of reassessment of falls risk following family reports of the deceased's compromised mobility. The Trust's investigation did not identify these concerns.
Response (Tameside and Glossop Integrated Care NHS Foundation Trust): • The Trust implemented a monthly audit of falls risk assessments on the Acute Medical Unit and conducts monthly Quality Assurance Rounds reviewing falls risk assessments. • The Falls prevention … (AI summary)
Responded
Francis Barnes
Concerns: 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.
Response (Oxford University Hospitals NHS Foundation Trust): • The Thames Valley Vascular Network developed and approved a concise procedure for contacting the OUH Vascular Team for emergencies. • Following an appraisal of options, a Microsoft 365 Form … (AI summary)
Responded
Emmanuel Ladapo
Concerns: The coroner noted insufficient engagement by C&I services with Mr Ladapo's family, and a psychiatrist omitted to ask about suicidal ideation during consultations despite noted deterioration. This indicates a gap in staff awareness regarding the importance of exploring suicidal feelings.
Overdue
Charlie Millers
Concerns: 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.
Response (Department of Health and Social Care): • The Patient Safety Incident Response Framework (PSIRF) became a contractual requirement for providers from April 2024, with the aim of increasing focus on learning from patient safety incidents. • … (AI summary)
Responded
Gordon Long
Concerns: The coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the agreed action plan had led to improvements in care.
Overdue
Megan Williams
Concerns: The coroner noted concerns about clinical staff's knowledge and clarity of the Acute Abdominal Pain Pathway, and that the hospital's Serious Incident process did not incorporate family information. A documented process for patients who self-discharge was also lacking.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated it did not consider that any actions from its organisation would address the issues raised. (AI summary)
Response (NHS England): • Regional colleagues are engaging with NHS Kent and Medway Integrated Care Board on the concerns raised. • NHS England has asked to be sighted on the Trust’s response and … (AI summary)
Response (East Kent Hospitals): • The Trust implemented a procedure requiring the Acute Abdominal Pain Pathway (AAPP) to be fully completed for patients admitted with abdominal pain and added the AAPP to the My … (AI summary)
Responded
Joan Knight
Concerns: 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.
Response (University Hospitals Birmingham NHS Foundation Trust): • The Trust requested that the speciality use recommended coding scores and disabled other coding fields on the legacy software. • The Trust identified specialities within the Trust using the … (AI summary)
Responded
Robert Taylor
Concerns: The coroner identified a lack of enhanced nursing observations for a patient who fell, and insufficient information on efforts to implement them. Concerns were also raised about the quality of the Trust's post-death investigations, which did not address this key issue.
Response (University Hospitals Birmingham NHS): • The Enhanced Care policy has been re-embedded, and communication regarding patients requiring enhanced observations and at risk of falls has been revised. • Falls training is being delivered to … (AI summary)
Responded
June Phillips
Concerns: The coroner identified concerns regarding inaccurate care home records not reflecting a patient's deterioration, the failure to update the falls risk assessment after a fall, and an inadequate post-falls investigation.
Response (Willow Grange Care Home): • A root analysis tool and an incident investigation form have been implemented. • The policy for residents on blood thinners who fall has been updated, requiring 999 to be … (AI summary)
Responded
Jean Pike
Concerns: Concerns were raised that a patient was discharged from Ward F without multi-disciplinary meetings with community professionals who had expressed significant safety concerns. The health board's internal investigation did not identify this lack of consultation, indicating a potential ongoing risk from insufficient multi-disciplinary decision-making.
Response (Swansea Bay University Health Board): • The Health Board reviewed discharge processes, developed Terms of Reference for Multi-Disciplinary Team (MDT) Ward meetings in April 2022, and revised a pre-discharge checklist in July 2022 to ensure … (AI summary)
Responded
Renate Mark
Concerns: 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.
Response (Northumbria NHS): • The Trust is briefing ward teams on the accurate use of 'witnessed' and 'unwitnessed' fall terminology. • The Strategic Falls Group will review and update the Integrated Falls Prevention … (AI summary)
Responded
David Tighe
Concerns: 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.
Response (Oxfordshire University Hospitals NHS Foundation Trust): • A working group was established and met to develop a Trust-wide Ryles tube policy, which will be presented by April 2025 and followed by staff training. • The trust … (AI summary)
Responded
Lorraine Parker
Concerns: 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.
Response (Royal Berkshire NHS Foundation Trust): • The Trust has deployed additional support for learning in some specialties, introduced new forms for capturing learning in general surgery Morbidity and Mortality (M&M) meetings, and is restructuring the … (AI summary)
Responded
Etta-Lili Stockwell-Parry
Concerns: The coroner noted concerns that an investigation into care was not thorough, lacking statements from directly involved doctors and relying on incomplete records. There was also insufficient contextual sharing of investigation findings with staff.
Response (Betsi Cadwaladr University Health Board): • The Health Board implemented a new Integrated Concerns Policy in September 2024, providing a single approach to incident, complaint, and mortality reviews and investigations. • A new training programme … (AI summary)
Responded
Karl Dunstan
Concerns: 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.
Response (Milton Keynes University Hospital NHS Foundation Trust): • The Trust discussed the case at its Grand Round and held inter-departmental discussions to review and optimise screening and triage systems. • The Trust liaised with neighbouring Trusts to … (AI summary)
Responded
Matthew Goldsmith
Concerns: 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.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): • The Trust implemented an Electronic Patient Record system to facilitate real-time recording of radiological decisions and advice. • A multidisciplinary review meeting was convened, and the case was presented … (AI summary)
Responded
Mohan Hothi
Concerns: The Trust did not investigate two unwitnessed falls sustained by a patient during a hospital admission under the Patient Safety Framework, raising concerns about its ability to identify and address sub-optimal practices. Evidence of remediation provided by the Trust was vague.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): • The Trust implemented an action plan in early 2025 to address an increase in inpatient falls, which included reviewing post-fall action plans and discussing all reported falls at weekly … (AI summary)
Responded
Malik Bunton
Concerns: 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.
Response (Ministry of Defence): • The RAF has reiterated the importance of continually developing welfare training for managers and will incorporate immediate fact-finding investigations for suspected suicides into policy. • An independent Learning Event … (AI summary)
Responded
Evie Muir
Concerns: 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.
Response (Mid and South Essex NHS Foundation Trust): • The Trust is undertaking a quality improvement programme to improve processes for learning from deaths, which will allow sharing of learning between teams and across hospital sites. • The … (AI summary)
Responded
Jet Thomas-Day
Response (Dorset County Council): Dorset Council has commenced a feasibility study, including a speed survey, to assess the appropriateness of the existing speed limit and consider additional advisory signage for the series of bends. … (AI summary)
Responded
Lacey Heath – Prevention of future deaths report
Concerns: 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.
Response (NHS England): • NHS England reported that Essex Integrated Care Board (ICB) has contacted providers to reinforce the Individual Funding Request (IFR) process for exceptional cases. • NHS England reported that Essex … (AI summary)
Response (Mid South Essex NHS Foundation Trust): • The Trust stated it would implement a high-risk anticoagulation pathway by the end of July 2026 to manage patients with persistent sub-therapeutic INR or complex needs. • The Trust … (AI summary)
Overdue
Neeshat Dalal – Prevention of future deaths report
Concerns: The coroner noted a need for funding to provide appropriately qualified dieticians to meet the nutritional needs of psychiatric inpatients within SPFT and other Trusts lacking such support.
Response (NHS England): • NHS England published Culture of Care Standards for mental health inpatient services in 2024. • NHS England is developing Allied Health Professional safer staffing standards, which will be considered … (AI summary)
Response (Department of Health and Social Care): • The Government has provided additional funding for health, with mental health spending forecast to increase to £16.1 billion in 2026-27. • The Mental Health Investment Standard remains in place, … (AI summary)
Responded
Christine Clegg- Prevention of future deaths report
Concerns: The NHS 111 script for minor wounds may inappropriately be applied to head injuries, leading to basic first aid advice instead of clinical assessment. Any injury above the neck should follow the head injury pathway to ensure a clinician provides advice.
Overdue
Peter Gurney
Concerns: The Ministry of Defence (MOD) has been aware of a possible link between exposure to nitrobenzene and other explosives and bladder cancer, yet active and past employees exposed to these substances have not been warned to get tested.
Response (Secretary of State for Defence): • The Ministry of Defence (MOD) stated it does not consider it appropriate to promote medical testing for bladder cancer in Explosive Ordnance Disposal (EOD) personnel, citing insufficient evidence for … (AI summary)
Responded
Select committee recommendations(11)
#42 —
Recommendation: 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 …
Response status not verified
#3 — Commission a multilateral development review to report on supported organisations' performance by 2026.
Recommendation: 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)
Response attribution not verified
#2 — Multilateral development review urgently needed for understanding ODA commitments and performance.
Recommendation: 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)
Response attribution not verified
#7 —
Recommendation: However, it is not clear that the Legacy Commission will have the power to do so under the bill as currently drafted. There is no principled reason why the Legacy Commission should not be able to produce ‘closed’ findings. Indeed, …
Response status not verified
#6 —
Recommendation: Public inquiries and courts using the Closed Material Procedure can create documents containing ‘closed’ findings, in addition to the published ‘open’ findings. Such ‘closed’ findings are an integral part of an investigation being effective and thorough in ascertaining the facts …
Response status not verified
#20 —
Recommendation: 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 …
Response attribution not verified
#19 —
Recommendation: 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 …
Response attribution not verified
#22 —
Recommendation: In the light of starkly disproportionate and tragic data on death rates from coronavirus of disabled people, including shocking figures for deaths of people, including young people, with learning disabilities, there must be a discrete independent inquiry into the causes. …
Response attribution not verified
#35 — Unknown scale of deaths and serious harms among vulnerable claimants
Recommendation: We remain concerned that the true scale of deaths and serious harms of vulnerable claimants is currently unknown. As set out by the Chief Medical Advisor, we recognise the complexity of these cases and that being in receipt of benefits …
Response attribution not verified
#11 —
Recommendation: We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, …
Response attribution not verified
#10 —
Recommendation: Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have …
Response attribution not verified
HSSIB safety recommendations(3)
Mental health inpatient settings
HSSIB recommends that the Department of Health and Social Care working with NHS England, and other relevant stakeholders, develop a comprehensive, unified data set with agreed definitions for recording and reporting deaths in mental health services to include deaths that …
Safety Recommendation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
HSSIB recommends that the Department of Health and Social Care working with NHS England, and other relevant stakeholders, develop a comprehensive, unified data set with agreed definitions for recording and reporting deaths in mental health services to include deaths that …
Safety Recommendation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
HSSIB recommends that the Department of Health and Social Care works with NHS England and other relevant stakeholders, to clarify national expectations for meaningful and restorative learning from patient safety events and deaths in mental health services. This is to …
Safety Recommendation
NCEPOD recommendations(8)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
CQC inspection actions(20)
West Suffolk Hospital
The trust should consider improving the quality of perinatal mortality and morbidity meeting minutes.
Should Do
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.
Must Do
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.
Must Do
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.
Must Do
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.
Must Do
Kidderminster Hospital and Treatment Centre
The trust must ensure that all assigned mortality reviews are completed within the 30-day target.
Must Do
Kidderminster Hospital and Treatment Centre
The trust must ensure that all assigned mortality reviews are completed within the 30-day target.
Must Do
Clatterbridge Hospital
The trust should ensure that mortality reviews are undertaken in a timely way.
Should Do
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.
Must Do
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 …
Should Do
North Tyneside General Hospital
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Must Do
Berwick Infirmary
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Must Do
Alnwick Infirmary
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Must Do
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.
Should Do
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.
Must Do
North Middlesex University Hospital
The trust must ensure that learning and improvements take place in a timely manner by ensuring the investigations into complaints, incidents and mortality are concluded within stated timescales.
Must Do
Stamford & Rutland Hospital
The service must ensure mortality and morbidity is reviewed regularly and incorporated into the governance of the service.
Must Do
Bridlington Hospital
The trust must ensure it has a robust process for identifying learning from deaths and serious incidents and ensure this is systematically shared across the organisation.
Must Do
The Royal London Hospital
The service should ensure that it completes thorough reviews of all serious incident to ensure that all incidents are categorised in line with national guidance to improve long term outcomes for mothers and babies.
Should Do
The Royal London Hospital
The service must ensure that it completes thorough reviews of serious incidents to ensure that all incidents are categorised in line with national guidance to improve long term outcomes for mothers and babies.
Must Do
PPO death in custody recommendations(5)
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.
The Governor at HMP Peterborough
The Governor at HMP Peterborough should ensure that a manager holds a hot debrief promptly after a death in custody and that all those involved in the incident, including healthcare staff, are invited to attend, in line with PSI 64/2011.
The Head of Healthcare, alongside doctors involved in Mr Honnor’s …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s care, should undertake a formal significant event analysis to identify weaknesses in the care provided and learning from these, and share these with all clinicians working in the prison.
The Governor of HMP Birmingham
The Governor should review how effective previous work to educate managers about the risk assessment process and the Graham judgment has been and provide additional measures, including additional training, where necessary.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a robust quality assurance process of reception and FNIP records to ensure that staff are following the agreed processes and recording and considering all risk factors for suicide and self-harm.
IMB annual reports(4)
Wymott (2021)
HMP Wymott largely maintained safety during a challenging Covid-19 reporting year (June 2020-May 2021), seeing reductions in self-harm and violence. While staff efforts and some initiatives were commendable, the pandemic exacerbated long-standing issues, particularly with healthcare provision, the prison estate's infrastructure, property loss, and complaints handling. The restricted regime severely limited opportunities for purposeful activity, education, and resettlement, causing significant frustration among prisoners.
PRISON
Key concerns
Standford Hill (2021)
HMP/YOI Standford Hill maintained a well-run, humane prison with a strong emphasis on rehabilitation, despite significant challenges from the Covid-19 pandemic. The Board commended staff dedication and positive prison culture, but raised concerns about healthcare provision following a death in custody, the lack of an internet room, and reliance on external kitchen facilities. The pandemic severely restricted regime activities and purposeful activity, impacting prisoner progression and wellbeing.
PRISON
Key concerns
Bullingdon (2021)
HMP Bullingdon faced significant challenges during the reporting year (July 2020 – June 2021), exacerbated by Covid-19 restrictions which led to extensive in-cell time and impacted various services. The Board noted chronic overcrowding, an increase in self-harm incidents, and persistent issues with staff experience levels and the provision of mental healthcare. Progression and resettlement efforts were hindered by a high turnover of prisoners, predominantly those on remand or serving short sentences, while the effectiveness of drug interception measures remains a concern.
PRISON
Key concerns
Altcourse (2020)
HMP Altcourse maintained safety and humane treatment during the COVID-19 pandemic, with low levels of self-harm and violence. Staff and prisoner morale remained high due to positive staff attitudes and good communication, despite severe regime restrictions. Key concerns include the challenges of housing an aging prison population, delays in mental health transfers, and persistent issues with prisoner property and food quality.
PRISON
Key concerns
IMB individual recommendations(13)
Ford (2021)
The Board is very concerned by the Prisons and Probation Ombudsman (PPO) report into the death in custody in 2020, which criticised the treatment of long-term medical conditions. We appreciate that the healthcare provider has changed since then but it is essential that the protocol is adhered to in all cases. See sections 6.8.1 and 6.8.2.
Governor / Director
Implemented
Oakwood (2025)
Although the IMB receives the Prisons and Probation Ombudsman PPO final report on deaths in custody, it no longer receives the clinical review which previously came as an annex to the report. Is it possible to allow access to such reports again?
HMPPS
Littlehey (2021)
With the high number of deaths in custody the Board asks whether the Governor will be focussing on the learning points from those that have occurred and, whether she will be addressing the number of trained family liaison officers (FLOs).
Governor / Director
Hewell (2021)
Please conclude the report into the death on 14 June 2018, so that any identified lessons learned may be acted upon.
Other
Noted
Bedford (2021)
The interim Prisons and Probation Ombudsman (PPO) reports on two deaths in custody raise some significant issues and we would ask that a clear action plan is put in place in response to the final reports.
Governor / Director
Noted
Swaleside (2022)
The Board shares the concerns expressed by the Senior Management Team regarding the number of deaths in custody during the year and appreciates that much investigation is being conducted by the LTHSE into the root causes of these. However, a national investigation is perhaps required to establish either commonality of cause irrespective of prison type or to highlight specific issues …
Ministry of Justice
In Progress
Altcourse (2022)
The prison was designated a ‘cluster death site’ in October 2021 but no additional support/training was forthcoming from the centre which would have been helpful in identifying any areas for development.
HMPPS
Leeds (2023)
Leeds is designated a ‘cluster site’, due to the numbers of deaths in custody over the past 12-plus months. Who makes the decisions about what actions are required to ensure that the ‘cluster site’ status may be removed?
Governor / Director
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Noted
Lowdham Grange (2025)
What is being done to ensure the mistakes and omissions highlighted in the recent Prevention of Future Deaths reports by the Coroner are not repeated?
Governor / Director
Wymott (2021)
How does the prison intend to ensure that the actions identified in the action plan following Prisons and Probation Ombudsman (PPO) reports into deaths in the prison are implemented effectively (see paragraph 4.2.3)?
Governor / Director
Swaleside (2024)
The Board shares the concerns expressed by the SLT that there have again been deaths in custody during the year, though these all appear to be of natural causes.
HMPPS
Implemented
Swaleside (2023)
The Board shares the concerns expressed by the SLT that there have again been deaths in custody during the year. A thorough investigation is being conducted by the LTHSE into the causes. However, a national investigation is perhaps required to establish either commonality of cause irrespective of prison type and to highlight specific issues relating to particular establishments.
HMPPS
Health investigations(45)
Independent investigation report into the care and treatment of Yusuf — Rec 2
Yusuf did not have a post-mortem, which has meant there was a missed opportunity to understand his underlying pathology more definitively. • The Trust should review its criteria and decision-making in relation to undertaking hospital post-mortems for children who die unexpectedly. This should result in readily available Trust guidelines, considering …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 20
The Panel recommends to the SHA that following any incident involving death or serious injury the Trust should undertake an immediate investigation, but the SHA should commission a fully independent inquiry as soon as possible so that the inquiry may start its investigations as soon as any legal proceedings have …
east_of_england
Independent investigation: Joseph Day, Folkestone (2001) — Rec 27
The East Kent Health Authority should ensure that the Coroner is provided with a copy of all independent investigation reports into deaths that may involve failings in mental health or social care services. This is to assist the Coroner in determining whether to reopen an inquest or to make recommendations …
south_east
Independent investigation: Carla Thompson, Merton (1998) — Rec 11
The Inquiry Panel recommends that the Department of Health should review the process for conducting independent investigations into homicides by mental health patients, with a view to streamlining the process and reducing the burden on professional staff, and that the 'Collaborative Review' process should be avoided in future.
london
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 7
Trusts should seek advice on the procedures to adopt immediately after a homicide (e.g., sequestering all records, and the composition of the internal inquiry/review team). Such advice could be obtained from Strategic Health Authorities or independent experts.
south_east
Independent investigation: Michael Young, Nottingham (2010) — Rec 5
There were omissions in the Mr S report that should have been identified and addressed via an effective quality assurance process. The Trust must therefore devise a common set of criteria against which each Level 2 serious untoward incident investigation report is benchmarked. This set of criteria must be implemented …
midlands
Independent investigation: Michael Young, Nottingham (2010) — Rec 4
The assessment of the Trust’s internal investigation has identified the need for Nottinghamshire Healthcare NHS Trust to further develop the standard of its serious untoward incident investigations and in particular the presentation of the investigation reports written, so that the investigation report: Clearly sets out the terms of reference to …
midlands
Independent investigation: Mark Murphy, Streatham (2006) — Rec One
It is recommended that Terms of Reference direct the investigation to complete a detailed chronology/timeline or events to enable the investigation to consider an appropriate length of time to capture key elements of the person’s care.
london
Independent investigation: Keith Bevis, Portsmouth (2013) — Rec 9
Serious Incident Review reports must fully comply with guidelines outlined in the National Patient Safety Agency’s RCA Investigation Evaluation Checklist.
south_east
Independent investigation: Keith Bevis, Portsmouth (2013) — Rec 8
Serious Incident Review authors should always utilise and demonstrate within their report the underpinning investigative methodology that they are using, e.g. a Fishbone analysis of contributory factors.
south_east
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.16
National guidelines on Homicide Inquiries should be clarified as to the necessity and nature of such inquiries especially when a minor is the subject.
north_west
Independent investigation: Jim Ward, Ayr (2007) — Rec 26
There must be clear splitting off of the function of staff support/debrief from an exacting examination of the facts. NHS Board A should develop guidance to issue to staff involved in CIRs to ensure that they are fully aware of the process and what will be involved.
scotland
Independent investigation: Jim Ward, Ayr (2007) — Rec 25
The Chair of any CIR must be, and be seen to be, independent to the service, have appropriate training in conducting CIRs and have expert knowledge of the subject area being reviewed.
scotland
Independent investigation: Jim Ward, Ayr (2007) — Rec 24
Until NHS QIS guidance is available NHS Board A must, as a matter of urgency, develop and implement policy governing CIRs. This should include direction with regard to when CIRs are required; who should be involved; the expertise of the Chair; the scope and purpose of the CIR; and the …
scotland
Independent investigation: Jim Ward, Ayr (2007) — Rec 23
NHS QIS should develop and oversee the implementation of a standardised process for critical incident reviews (CIRs) for use across all mental health services in NHS Scotland.
scotland
Independent investigation: Carl James, Swindon (2007) — Rec 4
An RCA panel investigating an incident of this gravity should be supported by a person, who understands the issues and is able to take comprehensive and attributed verbatim notes for greater understanding when referred to much later in the overall Investigation process.
south_west
Assurance Review: Trust recommendations — Rec 26
Mortality review (Link to R10 and R15) • Any post-operative death should be subject to rigorous and contemporaneous case review and monitored at Trust level. This would also help support accurate reports to the Coroner if required to be written some months post-death. • Death summaries and sudden death reports …
north_west
Assurance Review: Trust recommendations — Rec 15
Mortality review (Link to R10 and R26) • Following on from our recommendation on mortality review in our Draft Current Controls Assessment Report, the Trust must develop a robust mechanism for identifying deaths by speciality using both admission and treatment function codes and other identifiers. This should include deaths up …
north_west
Assurance Review: Trust recommendations — Rec 10
Mortality review (Link to R15 and R26) Every inpatient Urology death must have a case review conducted by Consultant Urologists with external support in using structured judgement review (SJR) methodology (Royal College of Physicians) or other recognised case note review methodology and be subject to Trust level scrutiny (as per …
north_west
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 61
Consider a revision to the Learning from Deaths guidance to ensure that patient records on death are suitably managed in original form by professionals to reduce the risk of posthumous amendment.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent review of the independent investigations for mental health … — Rec 3
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the Serious Incident Framework.
east_of_england
An independent investigation into the care and treatment of David: … — Rec 8
NHS Wigan CCG and NHS Knowsley CCG must ensure that all systems for ‘sign off’ of Trust SI reports provide quality assurance that the requirements of the NHS England SiF are met.
David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust
north_west
Accepted
An independent investigation into the care and treatment of David: … — Rec 7
The Trust and NHS Wigan CCG must ensure that all investigations and SI reports meet national quality requirements, to include particular reference to engaging with and listening to families.
David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust
north_west
An independent inquiry into the care and treatment of Mr … — Rec 13
We recommend that, where a service user who is involved in a homicide (or other SIRI) is receiving services from more than one NHS Trust, that a joint investigation should be carried out by those Trusts. NHS Improvement should include guidance to this effect in their review of the Serious …
Southern Health NHS Foundation Trust
south_east
An independent external quality assurance review (published November 2019) can … — Rec 9.
NHS Durham Dales, Sedgefield and Easington CCG, NHS North Durham CCG, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust and North East Ambulance Service should regularly and collectively review all deaths of patients transferred from MHSOP wards to A&E with suspected fragility fractures …
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 9.
NHS Durham Dales, Sedgefield and Easington CCG, NHS North Durham CCG, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust and North East Ambulance Service should regularly and collectively review all deaths of patients transferred from MHSOP wards to A&E with suspected fragility fractures …
north_east_yorkshire
This Independent Investigation into concerns and issues raised relating to … — Rec 31
The Trust Board should ensure that there is a robust and consistent process for learning from deaths, in line with national guidance, including detailed analysis of inpatient deaths by specialty/sub-specialty, and that this learning is regularly reported to the Board and used to drive service improvement.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
External review of all Independent Investigations following Mental Health Homicides — Rec 3
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the Serious Incident Framework.
south_west
External review of all Independent Investigations following Mental Health Homicides — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
south_west
An independent investigation into the multi-agency care and supervision of … — Rec 2
The West Midlands MAPPA Strategic Management Board did not complete a serious case review into this incident because this review was being completed. However, this review has not had access to the source material from the probation service. The West Midlands MAPPA Strategic Management Board (SMB) must reconsider its decision …
midlands
An independent investigation into the care and treatment of mental … — Rec 9
NHS Durham Dales, Sedgefield and Easington CCG, NHS North Durham CCG, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust and North East Ambulance Service should regularly and collectively review all deaths of patients transferred from MHSOP wards to A&E with suspected fragility fractures …
Tees Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review following an internal investigation … — Rec 2
The Trust should ensure that SI action plan evidence is rigorously tested and recorded in advance of action plan sign off.
A in Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation: Tracey Baker, Chard (2015) — Rec 15
Somerset Partnership NHS Foundation Trust should revised their Serious Incidents Requiring Investigation Policy and Procedure so that it documents the governance arrangements for: • domestic homicide review’s (DHR) individual management reports (IMRs) • monitoring arrangements of DHR’s action plans.
south_west
Independent investigation: Tracey Baker, Chard (2015) — Rec 14
Following a domestic homicide review (DHR), Somerset Partnership NHS Foundation Trust in partnership with SCCG should convene learning event for all the involved managers and practitioners.
south_west
*Independent investigation into the care and treatment of Mr A: … — Rec 14
West Hertfordshire Hospitals NHS trust should ensure that responses to reports from the Coroner are accurate and that procedures are in place to make sure that Rule 43 reports are identified and that information is collected and action considered within a governance process which is monitored by the trust board.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
An independent review of the investigation undertaken by Tees Esk … — Rec 2
The Trust should ensure that: • the quality assurance process for signing off serious incidents/homicides is strengthened and the reasons why this was not adequate in this case are understood • independence from services in investigations is given priority • the Integrated Care Board (ICB) is given sufficient opportunity to …
Tees Esk and Wear Valley NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review following an internal investigation … — Rec 1
Trust SI panel meetings should be formally recorded.
A in Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation: Joseph Day, Folkestone (2001) — Rec 15
The East Kent Health Authority should ensure that independent investigations into serious incidents are conducted in a timely, transparent, and thorough manner, with appropriate involvement of families and carers. The findings and recommendations of such investigations should be widely disseminated to promote learning and prevent recurrence.
south_east
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 20
A tabular timeline, or similar methodology, should be used in all local incident investigations so a more complete chronology is established. (II/DB)
london
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R16
The trust board should receive a six-monthly report on the progress of recommendations after serious untoward incidents (B).
midlands
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R14
The trust should develop a risk register which integrates the outstanding risks and recommendations identified from historical serious untoward incident investigations with other risk data (B).
midlands
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 67
NHS England and NHS Improvement should commission a Phase 5 review (Autumn 2022) in line with the Terms of Reference to include assurance on key elements such as: • continuity of care; • named Consultant; • MDT [multidisciplinary team] management; • follow-up patient pathways; • the quality of incident reporting …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent review of the independent investigations for mental health … — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
east_of_england
An independent inquiry into the care and treatment of Mr … — Rec R5
The trust should have a clear process in place to ensure that the victims of serious incidents and their families are supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family: are provided with and consulted on the terms of …
Mr S . At the time of the homicide (2011) Mr S was receiving care and treatment from Somerset Partnership NHS Foundation Trust
south_west
An independent investigation into the care and treatment of patient … — Rec 1
The Trust must develop its approach to individual investigations and develop a clear process for producing high-quality reports, that is compliant with PSIRF expectations. This should include: • clear guidance on which methodology to use, namely how the structured judgement review is used (outside mortality review processes) • agreement on …
north_east_yorkshire
Scottish Fatal Accident Inquiries(3)
Daniel McSweeney
Dec 2018
Evan Bruce Cameron
Mar 2019
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, wish it …
Sep 2017
Independent reviews(25)
Mental Health Taskforce 2016 — Rec 56
The Department of Health should ensure that the scope of the Healthcare Safety Investigation Branch includes deaths from all causes in inpatient mental health settings and that there is independent scrutiny of the quality of investigation, analysis of local and national trends, and evidence that learning is resulting in service …
Health & Social Care
Harris Review: Deaths in Custody — Rec 103
The Chief Coroner should be provided with sufficient resources to enable him to report on themes emerging from prevention of death reports involving deaths in custody.
Justice & Legal
Harris Review: Deaths in Custody — Rec 102
PPO and Coroners should be given the remit, where they think it appropriate, to look beyond the circumstances of any individual death to see whether there were other factors that occurred earlier in the prisoner’s history that might have contributed to the death.
Justice & Legal
Francis Inquiry (Mid Staffs 2010) — Rec 15
In view of the uncertainties surrounding the use of comparative mortality statistics in assessing hospital performance and the understanding of the term 'excess' deaths, an independent working group should be set up by the Department of Health to examine and report on the methodologies in use. It should make recommendations …
Health & Social Care
Laming Review (Baby P) — Rec 41
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to ensure Serious Case Reviews focus on the effective learning of lessons and implementation of recommendations and the timely introduction of changes to protect children.
Other
Laming Review (Baby P) — Rec 40
The Department for Children, Schools and Families should revise the framework for Serious Case Reviews to ensure that the Serious Case Review panel chair has access to all of the relevant documents and staff they need to conduct a thorough and effective learning exercise.
Other
Laming Review (Baby P) — Rec 39
The Department for Children, Schools and Families should revise Working Together to Safeguard Children so that it is explicit that the formal purpose of Serious Case Reviews is to learn lessons for improving individual agencies, as well as for improving multi-agency working.
Other
Wood Review of LSCBs — Rec 34
The Department of Health should consider the role that Health and Wellbeing Boards and the Joint Strategic Needs Assessment play in dealing with child deaths and the role of a CDOP.
Other
Wood Review of LSCBs — Rec 33
In considering a common national standard for high quality serious incident investigations for child death the Health Safety Investigation Branch of the NHS should consider the role CDOPs will play in this process.
Other
Wood Review of LSCBs — Rec 32
The Department of Health should determine how CDOPs can be organised on a regional basis with sub-regional structures to promote learning and dissemination. They should also give consideration to the membership of CDOP to ensure appropriate representation from both health and non-medical agencies.
Other
Wood Review of LSCBs — Rec 31
If the national study recommends the introduction of a national database for CDOPs, the Department of Health should consider expediting its introduction.
Other
Wood Review of LSCBs — Rec 30
That the national sponsor for CDOPs should move from the Department for Education to the Department of Health. It should consider how CDOPs can best be supported and sponsored within the arrangements of the NHS.
Other
Wood Review of LSCBs — Rec 25
On the creation of the new body, to end the national panel of independent experts on SCRs.
Other
Wood Review of LSCBs — Rec 21
To discontinue Serious Case Reviews, and to establish an independent body at national level to oversee a new national learning framework for inquiries into child deaths and cases where children have experienced serious harm.
Other
Munro Child Protection Review — Rec 9
The Government should require LSCBs to use systems methodology when undertaking Serious Case Reviews (SCRs) and, over the coming year, work with the sector to develop national resources to: ●● provide accredited, skilled and independent reviewers to jointly work with LSCBs on each SCR; ●● promote the development of a …
Other
Morecambe Bay Investigation — Rec 40
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 …
Health & Social Care
Morecambe Bay Investigation — Rec 39
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 …
Health & Social Care
Morecambe Bay Investigation — Rec 38
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 …
Health & Social Care
Morecambe Bay Investigation — Rec 23
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation …
Health & Social Care
Wessely Review — Rec 34
Guidance should make clear that a death under DoLS/LPS in a psychiatric setting should be considered to be a death in state detention for purposes of triggering the duty for an investigation by a coroner and an inquest with a jury should be held.
Health & Social Care
Accepted
Ockenden Review — Rec 6
Learning from maternal deaths. Essential action: Nationally all maternal post-mortem examinations must be conducted by a pathologist who is an expert in maternal physiology and pregnancy related pathologies. In the case of a maternal death a joint review panel/investigation of all services involved in the care must include representation from …
Health & Social Care
Accepted
Jones: Patronising Disposition Review — Rec 17
The government has not responded publicly to warnings about the state of pathology provision in England and Wales made in a 2015 Home Office-commissioned review conducted by Professor Peter Hutton, or to warnings made by the Chief Coroner in his 2015-2016 annual report. Both raise important concerns which government should …
Policing & Security
Jones: Patronising Disposition Review — Rec 15
It is difficult to overstate the impact of the failures of pathology at the first inquest. The impact is deeply personal for those families who feel they will now never know how their loved one died, but it also has a wider resonance – leading as it did to the …
Policing & Security
Jones: Patronising Disposition Review — Rec 18
I would encourage the Chief Coroner to ensure that all coroners are made aware of the experience of the Hillsborough families as set out in this report. Coroners should ensure that the decisions they make on toxicology – especially in respect of children – are made in a sensitive way, …
Policing & Security
Laming Review (Baby P) — Rec 44
Local Safeguarding Children Boards should ensure all Serious Case Review panel chairs and Serious Case Review overview authors are independent of the Local Safeguarding Children Board and all services involved in the case and that arrangements for the Serious Case Review offer sufficient scrutiny and challenge.
Other
PHSO casework decisions(5)
P-001459 — United Lincolnshire Hospitals NHS Trust
Mrs N complained staff did not fully investigate her husband's initial symptoms, and about a fall, catheter delays, nutrition, oral thrush treatment, and end-of-life decisions during later admissions.
NHS in England
Partly Upheld
Jul 2022
P-003690 — A practice in the Amber Valley area
Ms B complained a doctor did not take her mother's health concerns seriously or refer her for treatment on 17 March 2023, potentially contributing to her death.
NHS in England
Jul 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complained the Trust failed to diagnose her father after surgery, poorly managed sepsis, lacked awareness of blood clots, and did not refer his death to the coroner, causing his death.
NHS in England
Sep 2025
P-002443 — Hull University Teaching Hospitals NHS Trust
Ms F complained her daughter was admitted to ICU too late, the source of internal bleeding wasn't found or treated, and the death certificate listed an incorrect cause.
NHS in England
Feb 2024
P-003268 — Portsmouth Hospitals University NHS Trust
Mrs A complained doctors did not properly investigate her husband's condition, made incorrect diagnoses, and delayed an MRI scan during his last four months, questioning if his death was avoidable.
NHS in England
Not Upheld
Jan 2025
LGO / SPSO decisions(3)
NIPSO-202003319 — Northern Health and Social Care Trust
A woman whose father died in Causeway Hospital after removing his oxygen mask believed he should have been monitored more closely. She also questioned why the Trust did not commission a review into the incident.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
NIPSO-202002627 — Northern Health and Social Care Trust
The Northern Trust failed to act on a woman’s concerns about her mother’s health. This, as well as its failure to properly assess her spinal injury and accurately read the results of an MRI scan, led to her untimely death.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
21-018-958 — Leeds City Council
Summary: We will not investigate this complaint about Mrs Y’s death in a care home, which the family believe was due to choking on meat. We could not say that any fault had caused injustice to Mrs Y and her family, because a coroner found Mrs Y did not die …
LGO (Local Government & …
Adult Care Services
May 2022
Domestic Homicide Reviews(66)— showing 50 strongest matches
Rotherham — recommendation 17.3
The Home Office is invited to consider the provision of greater clarity around the definition of a DHR to include victim suicide and serious injury
Home Office
Home Office
West Lancashire — recommendation 6
WLCSP to encourage all agencies that have formed part of this Panel to ensure a process is in place to identify domestic abuse victim suicides and ensure they are considered for a DHR
Lancashire Constabulary | West Lancashire Community …
Lancashire Constabulary
Gloucester — recommendation 15
If there is another DHR in Gloucestershire, Safer Gloucestershire to provide a workshop for agencies on writing clear and analytical IMRs for domestic homicide reviews.
Safer Gloucestershire
West Berkshire — recommendation 8
We recommend that the Home Office revise the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, to make clear the criteria that need to be met for a DHR Panel Chair to be considered fully independent.
Home Office
Home Office
Bristol — recommendation 2
As part of the consideration of the DHR process, greater flexibility could be given to Community Safety Partnerships to only review those suicides where Domestic Abuse appears to have been a significant and primary influence on the decision of the person to take their own life.
Home Office
Home Office
Bristol — recommendation 1
The Home Office reviews both the title of Domestic Homicide Reviews and the content of its Guidance document in the context of deaths occurring from suicide.
Home Office
Home Office
Harlow — recommendation 15.10.4
Consideration should be given to the status of an unborn child who is delivered within a homicide situation. As the victim's baby was not born there was no birth certificate, and as she was not recorded as a stillbirth there was no certificate to state that either. However the judicial …
All Agencies
Nottingham — recommendation 1
Nottingham Community Safety Partnership to ensure that an intersectionality review is undertaken at the outset of every Domestic Homicide Review, that the principle predominating protected characteristics are considered and the panel are provided with a view about those characteristics.
Nottingham Community Safety Partnership
Norfolk — recommendation 1
To avoid delays in the completion of a Domestic Homicide Review where an IOPC inquiry is taking place concurrently, the IOPC concluding report should be expedited promptly, and made available to the DHR Panel within 6 months of the verdict concluding the criminal trial to enable all relevant information to …
Independent Office for Police Conduct
Independent Office for Police …
Cornwall — recommendation 7
That the learning from these domestic homicide reviews is routinely shared with professionals working within adult and children’s services to facilitate proactive support that could minimise the potential for escalating risk or reoccurrence within the next generation.
NHS England
NHS England
Leicester — recommendation National - 1
The Home Office to consider clearer parameters in its next iteration of the statutory guidance for undertaking DHRs in the context of suicides.
Home Office
Home Office
Bridgend — recommendation 3
The Chair of Bridgend Community Safety Partnership requests the Home Office for further clarification of paragraphs 99 and 100 of the new Home Office Guidance for the Conduct of Domestic Homicide Reviews December 2016, especially regarding the term ‘The Department of Health is clear that, where there is evidence to …
Home Office | Medical Regulatory Bodies …
Home Office
South Norfolk — recommendation 17.12
The Home Office to consider whether the methodology for a DHR could be modified for a more proportionate review, when the perpetrator is not of sound mind and the victim has not experienced domestic abuse.
Home Office
Home Office
Cardiff — recommendation 2
The Home Office Quality Assurance Panel provides additional information and clarity with regards to the Home Office Guidance for the conduct of Domestic Homicide Reviews dated December 2016. Particular clarification is required of paragraphs 99 and 100 that relates specifically to Health Service support to such reviews. This is critical …
Home Office Quality Assurance Panel
Cardiff — recommendation 1
That the outcomes of both the Child Practice Review and the Domestic Homicide Review are shared and considered by the Cardiff Public Services Board and any consistent themes are acted upon in a coordinated way.
Cardiff Public Services Board
Sandwell — recommendation 5
That; in order to optimise the use of agencies’ resources (notably time and money) most effectively and efficiently, whilst still achieving the purpose of the domestic homicide review; the Safer Sandwell Partnership asks the Home Office to consider the option of different approaches to the undertaking DHRs in different circumstances …
Home Office
Home Office
Kent — recommendation bullet_5
KMPT should review their IMR process when internal reviews have already been completed to ensure all relevant matters are included in the IMR.
Kent and Medway NHS and Social …
Kent and Medway NHS …
Kent — recommendation bullet_3
The issue of GPs providing reports as opposed to IMRs conducted by an independent GP requires consideration by the Kent and Medway Community Safety Partnership with a view to raising it with the Home Office to consider including GPs in the DHR process.
Kent and Medway Community Safety Partnership
Wiltshire — recommendation 7
Commission a Root Cause Analysis review under the AWP Incident Management policy, alongside any future Domestic Homicide Reviews and implement any actions that arise.
Avon & Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Aylesbury Vale — recommendation Panel Recommendation
The Home Office reviews the existing Domestic Homicide Review Guidance (2016) particularly the current suggested guidance for the timeframes to complete a homicide review. New guidance should also give more specific guidance to Police Services and other key agencies about the completion of IMRs to ensure they are completed fully …
Home Office
Home Office
Norfolk — recommendation 5.6.1
It is recommended that, despite the strengthening of the latest statutory guidance more work needs to be done to ensure the co-operation of GPs with Domestic Homicide Reviews. As the problem in this case appears to have been, in part, the payment to be made for engagement, it is recommended …
Government
UK Government
Southampton — recommendation 4
That the Home Office consider allowing more flexibility in the guidance for DHRs to allow local Community Safety Partnerships to make a case for not completing such a review where the circumstance of a homicide do not fall within the spirit of the guidance, as for example in this case …
Home Office
Home Office
Bracknell Forest — recommendation 7
The Crown Prosecution Service (Essex) did not supply an IMR for this DHR. A one page letter was received subsequently. The Attorney General’s Office should be contacted, this may well be best through the Home Office, initially. This is also linked to Recommendation 2.
Attorney General’s Office | Home Office
Attorney General's Office
Bracknell Forest — recommendation 6
The Home Office will be asked to note that the UKBA did not supply an IMR for this DHR. However a witness statement was produced. This is also referred to in Recommendation 2.
Home Office
Home Office
Bracknell Forest — recommendation 4
The terms of reference for future DHRs going forward need to mention relevant background information such as court transcripts, where appropriate. In addition, again where appropriate, an early invitation from the DHR to the Police’s Senior Investigation Officer should be built into the terms of reference of DHRs.
DHR Panels
Bracknell Forest — recommendation 3
The key organisations that represent the statutory organisations on the DHR Panel should ensure that the officers they delegate for attendance have sufficient authority to enable the DHR Panel to administer its statutory responsibilities appropriately.
Key organisations on the DHR Panel
Bracknell Forest — recommendation 2
The Home Office is also asked through this report to review how it might best remind key statutory agencies of their responsibilities in engaging with DHRs. Please see recommendation 6 & 7.
Home Office
Home Office
Bracknell Forest — recommendation 1
At a local level organisations required to produce IMRs require a better familiarity with the statutory basis for conducting DHRs and their role and responsibilities in engaging with these activities. The Community Safety Partnership is best placed to consider this matter further.
Community Safety Partnership
Norfolk — recommendation 1
The Home Office Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews Section 2 subsection 4 should be amended to specifically include GP practices as having a duty to participate in a Domestic Homicide Review and to have regard to any guidance issued by the Secretary of State
Home Office
Home Office
Croydon — recommendation 20
The Joint Strategic Needs Assessment on domestic violence should reference the findings of the two Croydon Domestic Homicide Reviews.
Croydon Council Public Health
Croydon — recommendation 3
Disseminate learning from the two Croydon Domestic Homicide Reviews widely across the partnership. This should be in the form of a written briefing to all staff and dissemination sessions and incorporating findings into any domestic violence training that is commissioned and delivered locally.
Croydon Community Safety Partnership
Reigate and Banstead — recommendation Recommendation Nine
RBBC CSP to highlight the need for the Home Office to consider updating the Multi Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (2016 to include specific guidance where a person may have taken their own life.
RBBC CSP
Reigate and Banstead — recommendation Recommendation Six
Learning from this DHR to be disseminated via a workshop organised by RBBC/SSAB and the Independent Chair.
RBBC | SSAB
Sandwell — recommendation 8
That SSP put in place appropriate measures to satisfy itself that all recommendations arising from this Domestic Homicide Review i.e. including those contained in the IMRs of partner agencies are fully implemented and the lessons arising from them are embedded into procedure and practice.
Safer Sandwell Partnership
Manchester — recommendation 4
The CSP should make representation to NHS England regarding the criteria for Mental Health Homicide reviews. The panel believes that this case would have benefited from such a review
Community Safety Partnership
Kent — recommendation 9
Reference has been made to the variable quality of the IMRs. Several did not follow the template or adequately address the terms of reference. This was particularly a problem within health. It is recommended, therefore, that the revised training and standard letters/support materials be implemented and its impact evaluated so …
All agencies
Ealing — recommendation 1A
Work with NHS England to clarify responsibilities and requirements of commissioning GP IMRs to help resolve issues with delays and quality of GP IMRs submitted to DHRs.
Home Office | Department of Health
Home Office
Milton Keynes — recommendation 1
The Hertfordshire multi-agency risk assessment conference (MARAC) sub-group should consider which organisation, agency or individual is best placed to undertake an independent review the MARAC records and produce an individual management review for any potential future domestic homicide reviews.
Hertfordshire multi-agency risk assessment conference (MARAC) …
Sheffield — recommendation 4.1.8
That the likely support needs of families and DHR subjects are assessed by future DHR panels when creating terms of reference for future DHRs. These support needs should be actively considered through the process of completing any future DHRs with any relevant learning in relation to supporting families shared appropriately. …
Domestic Abuse Strategic Board
Cardiff — recommendation 16.2b
That a national review of completed domestic homicide reviews (and other publications) be commissioned to determine the extent to which dating websites feature in background circumstances of cases, to enable consideration to be given as to what advice, if any, may be given to dating website users about their own …
Welsh Government
Welsh Government
Gloucestershire — recommendation 3
That Safer Gloucestershire ensure a thematic review is undertaken. The aim of the thematic review should be to bring together the learning from all suicide reviews in the county and ensure links are made with the GSPPF to develop a multi-agency plan for local activity to respond to common themes …
Safer Gloucestershire
Carmarthenshire — recommendation 20
Review terminology of ‘Domestic Homicide Review’ to reflect the range of deaths that fall within the criteria for a review
Home Office
Home Office
Cardiff — recommendation Recommendation Two
The Home Office Quality Assurance Panel provides additional information and clarity with regards to the Home Office Guidance for the conduct of Domestic Homicide Reviews dated December 2016. Particular clarification is required of paragraphs 99 and 100 that relates specifically to Health Service support to such reviews. This is critical …
Home Office Quality Assurance Panel
Wokingham — recommendation 5
We recommend that the appropriateness of the use of the DHR process in cases where individuals have taken a decision mutually end their lives, is considered by policy makers nationally to ensure a proportionate and appropriate response to any future instances such as that examined by this review.
Home Office
Home Office
Wokingham — recommendation 4
We recommend that the NHS England regional team work with SCAS to develop their understanding of conducting IMRs to an appropriate standard and that SCAS then embed this within their operating policies.
NHS England regional team | South …
South Central Ambulance Service …
Bristol — recommendation 17.3
As part of the reform of Domestic Homicide Review Statutory Guidance, the Home Office should consider whether homicides involving acute mental health episode meet the criteria for a Domestic Homicide Review.
Home Office
Home Office
West Berkshire — recommendation 5
As a Quality Assurance process, all IMRs be reviewed by the SIRI Review Group or a specifically named sub group of the SIRI Review Group Panel, to ensure that investigations provided by any SCAS member of staff, meet the required standards as set out in the Home Office Multi-Agency Statutory …
South Central Ambulance Service NHS Foundation …
South Central Ambulance Service …
Telford and Wrekin — recommendation 8
Safer Telford and Wrekin to ensure that a suicide prevention specialist sits on all future Domestic Abuse Related Death Reviews involving suicide in their area
Safer Telford and Wrekin
Cornwall — recommendation 6
NHS Kernow to refer this case to [the hospital] for discussion at the morbidity and mortality meeting.
NHS Kernow
NHS Kernow
South Norfolk — recommendation 17.3
The Home Office considers how to protect the anonymity of the DHR report for small rural communities.
Home Office
Home Office