Misleading Information to Coroner
Concerns regarding a local council providing potentially misleading or incomplete information to a coroner about a death.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
77match
82 - Metropolitan Police investigation into Lambeth Council
The Metropolitan Police Service should consider whether there are grounds for a criminal investigation into Lambeth Council's actions when providing information to the coroner about the circumstances surrounding LA-A2's death.
Matched on
terms: coroner, information
Inquiry recommendation
73match
ETI-20 - Prohibition on Misleading Reports from ALEOs
The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm’s-length external organisation (“ALEO”) wholly owned by the local authority that is the promoter and owner of the project, should not submit to the local authority information that is deceptive or reports that are misleading either...
Matched on
terms: information, misleading
PFD report
69match
Darren Goddard
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Matched on
terms: information, misleading
PPO recommendation
69match
The Governor
The Governor should ensure that information published on social media about a prisoner’s death is appropriate, accurate and that the nature of the death is not revealed until confirmed by HM Coroner.
Matched on
terms: coroner, information
PFD report
61match
Timothy Clayton
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Matched on
terms: coroner
PFD report
61match
Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Matched on
terms: misleading
PFD report
57match
Alex Blake
Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Matched on
classifier match
IMB recommendation
52match
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Matched on
terms: coroner
Inquiry recommendation
52match
ETI-21 - Duty of Officials to Councillors
Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to provide accurate reports to councillors to enable them to take informed decisions based upon the reality of the situation. Such reports should not be misleading either by the...
Matched on
terms: misleading
PHSO casework decision
51match
P-003908 - Epsom and St Helier University Hospitals NHS Trust
Dr U complained a Trust nurse gave misleading information about her son, failed to update records with dietician letters, and sent false information to his school.
Matched on
terms: information, misleading
Committee recommendation
51match
#8 - First Report - Direct-to-consumer genomic testing
Several contributors to this inquiry expressed concern that the information provided to consumers before and after using a direct-to-consumer genomic test, as well as the advertising used to market direct-to-consumer genomic tests, did not do enough to address public misconceptions of the capability of these tests and clarify the clinical utility of the results generated. Even where advertising...
Matched on
terms: information, misleading
LGO / SPSO decision
50match
21-018-329 - Surrey County Council
Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. Further investigation on this point will not lead...
Matched on
terms: coroner, information
PFD report
49match
Marcus McGuire
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Matched on
classifier match
Inquiry recommendation
48match
30 - National protocol on duties relating to inquests
A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to...
Matched on
terms: coroner
Committee recommendation
48match
#11 - 1st Report - The Coroner Service
The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient by themselves to prevent large multi-handed inquests, where individuals’ and organisations’ reputations are at stake, from becoming adversarial.
Matched on
terms: coroner
LGO / SPSO decision
47match
21-011-697 - Surrey County Council
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
Matched on
terms: coroner
LGO / SPSO decision
46match
25-011-009 - London Borough of Lambeth
Summary: We will not exercise discretion to investigate this complaint about the Council’s officers giving misleading information to the BBC in a broadcast in July 2024. This complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest that Mr X could not have complained to us sooner.
Matched on
terms: information, misleading
PFD report
45match
Roy Travers
There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.
Matched on
classifier match
Committee recommendation
44match
#9 - 1st Report - The Coroner Service
Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We encourage the new Chief Coroner to strengthen guidance and training on disclosure and pre-inquest reviews, emphasising to coroners...
Matched on
terms: coroner
LGO / SPSO decision
43match
21-007-703 - West Northamptonshire Council
Summary: Mr B says the Council misled the Planning Committee which influenced its decision to grant planning permission. Although officers failed to correct one piece of information at the Committee meeting there is no evidence this affected the final decision.
Matched on
terms: information
LGO / SPSO decision
43match
22-006-656 - London Borough of Croydon
Ms X complains about the council staff misleading the criminal justice system.
Matched on
terms: misleading
IMB recommendation
42match
Ford (2020)
Rehabilitation should be at the forefront of policy decisions relating to the open estate and your department’s handling of the Coronavirus Job Retention Scheme (“furlough”) was deplorable. Conflicting and misleading information has almost certainly led to some men leaving the prison system disadvantaged by significant amounts of money with which to re-enter the community at a time when...
Matched on
terms: information, misleading
Committee recommendation
39match
#11 - First report - Missing in action: UK leadership and the withdrawal from Afghanistan
The FCDO has repeatedly given us answers that, in our judgement, are at best intentionally evasive, and often deliberately misleading. On Nowzad, they only admitted that the case had been in any way unusual when faced with the evidence of whistleblowers. At best, the Permanent Under-Secretary displayed a worrying lack of knowledge of the department he leads, and...
Matched on
terms: misleading
PHSO casework decision
39match
P-002626 - A practice in the North Yorkshire area
Mrs N complained a GP practice shared inaccurate information with a mental health tribunal in 2019, causing an incorrect decision and significant distress.
Matched on
terms: information
PHSO casework decision
39match
P-004230 - University Hospitals Birmingham NHS Foundation Trust
Mrs H complained her right lung was damaged during a biopsy in 2016, causing worsened breathing difficulties. She also alleged inaccurate information about who performed the surgery.
Matched on
terms: information
PHSO casework decision
39match
P-003153 - A practice in the Oadby and Wigston area
Mr A complained the GP Practice failed to visit his brother after hospital discharge, leading to his death, and recorded incorrect information on the death certificate, causing distress.
Matched on
terms: information
PHSO casework decision
39match
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.
Matched on
terms: coroner
PHSO casework decision
38match
P-002056 - A dental practice in the Croydon area
Mrs O complained a dental practice provided misleading information before treatment, resulting in tooth loss, ongoing discomfort, and psychological damage.
Matched on
terms: information, misleading
Inquiry recommendation
36match
R68 - Consultant involvement in death certificates
Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patient’s care is involved in the completion of the death certificate wherever practicable, and that such involvement is clearly recorded in the patient records. Regular auditing of this process should take place.
Matched on
classifier match
IMB recommendation
36match
Wandsworth (2024)
In the past year, the IMB was not always informed of major incidents, particularly Deaths in Custody. Can you assure us that you will put a process in place to rectify this?
Matched on
classifier match
Committee recommendation
35match
#22 - Sixth Report - Stolen years: combatting state hostage diplomacy
UK nationals have been let down by the information shared by Ministers— actions which were counterproductive and may have contributed to less favourable conditions for an earlier release. Coherence and accuracy are vital not only in fairness to the families involved, but also to send the message to countries that may consider using detainees as leverage, that the...
Matched on
terms: information
PHSO casework decision
35match
P-004714 - University Hospitals Birmingham NHS Foundation Trust
Mr A complained his father was sexually assaulted by another patient, alleging the Trust knew of the risk but failed to safeguard and later provided false information in its response.
Matched on
terms: information
PHSO casework decision
34match
P-004147 - Lancashire Teaching Hospitals NHS Foundation Trust
Miss U complained about delayed stroke treatment, inconsistent information, early induced coma exit, and conflicting accounts, believing these contributed to her father's death.
Matched on
terms: information
Committee recommendation
32match
#7 - 2nd Report - Espionage cases and the Official Secrets Acts
We did not find evidence of deliberate efforts to obstruct the prosecution. The sequence of events nevertheless raises some substantial questions of whether the Government officials and counsel working on the DNSA’s witness statements could have found an alternative formulation which remained in line with the government’s overarching position at the time. This would have made clear that...
Matched on
classifier match
Committee recommendation
32match
#5 - 2nd Report - Espionage cases and the Official Secrets Acts
It is regrettable that the prosecution hinged on the testimony of a Government witness who would not state directly that China posed an active threat to national security at the material time. We acknowledge 48 however the arguments from the Crown Prosecution Service that, once the decision had been taken to rely on the Deputy National Security Adviser...
Matched on
classifier match
Committee recommendation
32match
#3 - 2nd Report - Espionage cases and the Official Secrets Acts
The witness statements provided by DNSA were however clear that China posed a range of threats to the United Kingdom’s national security. In our view it is plain that, taken together, these amounted to a more general active threat to the United Kingdom’s national security. We appreciate the legal argument that these positions are not identical. We regret...
Matched on
classifier match
Committee recommendation
32match
#2 - 2nd Report - Espionage cases and the Official Secrets Acts
The Deputy National Security Adviser (DNSA) would not describe China as posing an “active threat” to national security at the relevant time. We acknowledge the position from the Crown Prosecution Service that it would undermine their case that China represented such a threat if the DNSA, their central expert witness, refused to characterise China in such terms. (Conclusion,...
Matched on
classifier match
PHSO casework decision
32match
P-003667 - South Tyneside and Sunderland NHS Foundation Trust
Mrs O complained the Trust failed to inform her husband his cancer was untreatable and provided inappropriate post-operative nursing and discharge, denying them preparation time.
Matched on
classifier match
PPO recommendation
31match
The Governor of The Mount
The Governor of The Mount should ensure that all evidence, including electronic evidence, relevant to a death in custody is retained and made available to the PPO in line with PSI 58/2010.
Matched on
classifier match
PHSO casework decision
31match
P-004785 - A practice in the Torbay area
Mr A complained the practice incorrectly completed his father’s death certificate, didn't provide an amended certificate without cost, and mishandled his complaint.
Matched on
classifier match
PHSO casework decision
30match
P-004707 - A practice in the Chesterfield area
Mr L complained the Practice provided unclear information, a doctor misled him about a referral and misrepresented old records, and the Practice lied in its complaint response.
Matched on
terms: information
PHSO casework decision
30match
P-003062 - Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complained about her uncle's inappropriate discharge, incorrect falls risk assessment, lack of a Zimmer frame, and inaccurate information about his mobility, leading to readmission.
Matched on
terms: information
Committee recommendation
27match
#2 - Seventh report - Parliamentary and Health Service Ombudsman Scrutiny 2019–20
In May 2020, the PHSO reported to the Committee that it had experienced an increase of 13 per cent in demand compared to the previous financial year. Due to the introduction of a new digital casework management system, comparisons between years were not possible. This means that the 13 per cent figure cannot be evidenced. The PHSO made...
Matched on
classifier match
Committee recommendation
27match
#22 - Sixth Report - Parliamentary and Health Service Ombudsman Scrutiny 2021–22
The Committee was disappointed to learn that some of the data provided by the PHSO to inform the Committee’s PHSO Scrutiny 2020–21 Report had been revised unjustifiably ahead of this year’s inquiry, preventing easy comparability between reports. For the Committee to accurately fulfil its responsibilities to assess the performance of the PHSO, it is vital that the PHSO...
Matched on
classifier match
Article 2 learning point
27match
TA — HMP Chelmsford - LP 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
Matched on
classifier match
Article 2 learning point
27match
Mr Adakite — HMP Birmingham - LP 18
The list of documents to be retained as set out in PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults where an independent investigation will be necessary should mirror that in PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others (Safer Custody).
Matched on
classifier match
Article 2 learning point
27match
Mr Adakite — HMP Birmingham - LP 17
All relevant documentation relating to a prisoner following an incident that may result in an investigation under Article 2 should be promptly secured.
Matched on
classifier match
PHSO casework decision
27match
P-001720 - A practice in the Wirral area
Mr O complained his GP practice failed to correctly interpret blood pressure and cholesterol results from 2016-2018, leading to his chronic heart disease diagnosis.
Matched on
classifier match
PHSO casework decision
27match
P-004371 - Lewisham and Greenwich NHS Trust
Mrs E complained about delays in her father's care and discharge, an unfair COVID-19 test request, and false claims about medication delivery, causing distress.
Matched on
classifier match
IMB recommendation
27match
Lancaster Farms (2023)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody or the use of the special cell, are implemented. And that the Board receives responses to issues it raises in its weekly reports.
Matched on
classifier match