Clinical negligence harms learning
179 items
2 sources
Clinical negligence litigation hindering patient safety learning by focusing on blame rather than system-wide analysis.
Cross-Source Insight
Clinical negligence harms learning has been flagged across 2 independent accountability sources:
61 inquiry recs
118 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (61)
BRIS-119 — Abolish clinical negligence system, establish expert group for alternative patient compensation.
Recommendation: In order to remove the disincentive to open reporting and the discussion of sentinel events represented by the clinical negligence system, this system should be abolished. It should be replaced by an alternative system for compensating those patients who suffer …
Unknown
BRIS-37 — Urgently review compensation system for medical harm, replacing clinical negligence
Recommendation: There should be an urgent review of the system for providing compensation to those who suffer harm arising out of medical care. The review should be concerned with the introduction of an administrative system for responding promptly to patients’ needs …
Unknown
10 — Indemnity regulation reform
Recommendation: We recommend that the Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by this Inquiry and introduce a nationwide safety net to ensure patients …
Gov response: Accepted in principle. Medical defence organisations launched a voluntary Code of Practice for discretionary indemnity on 6 January 2025. DHSC commissioned an independent evaluation of the Code. Government continues to consider further policy options to …
Accepted in Part
In progress
IBI-1 — Compensation Scheme
Recommendation: My principal recommendation remains that a compensation scheme should be set up now
Gov response: The Infected Blood Compensation Authority (IBCA) was established through the Victims and Prisoners Act 2024. Scheme regulations came into force August 2024 with first payments made December 2024. As of October 2025, over £1.35 billion …
Accepted
Delivered
IBI-3c — Inquiry Website Preservation
Recommendation: The Inquiry website is maintained online
Gov response: The Inquiry website will be maintained with full functionality. Transfer to National Archives is under consideration.
Accepted
In progress
IBI-A-3a — HIV Eligibility Start Date
Recommendation: An amendment to the Regulations be made as soon as possible to remove the reference to 1 January 1982 from Regulation 3.
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at the Scheme's eligibility criteria for people infected with HIV. The Inquiry went on to recommend that the …
Accepted
In progress
IBI-A-4a — Interferon Treatment Impacts
Recommendation: People infected with Hepatitis B or C who have received a course of treatment with or based on interferon should be recognised as entitled to core awards at Level 3.
Gov response: The impact of interferon treatment on those infected with Hepatitis B or C often resulted in severe side effects, both psychological and physical. The Inquiry recommended that more be done to recognise the impact of …
Accepted in Part
In progress
IBI-A-4b — Special Category Mechanism
Recommendation: The Government reconsider whether to maintain its rejection in February 2025 of the recommendations of Sir Robert Francis KC and advice from the Infected Blood Inquiry Response Expert Group of August 2024, which was expressly accepted at the time by …
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the Scheme reflects the existing Special Category Mechanism and its equivalents. The England Infected Blood Support …
Accepted in Part
In progress
IBI-A-4c — Effective Treatment - Earnings Floor
Recommendation: For the calculation of Financial Loss awards for Hepatitis B, people born after 1953 should be treated like those born in or before 1953 on provision of evidence that their health did not improve or that it remained difficult to …
Gov response: The Government acknowledges the concerns raised by the Inquiry regarding the calculation of financial loss awards for individuals with Hepatitis B or C. Currently the amount awarded is determined partially by reference to the introduction …
Accepted
In progress
IBI-A-4d — Deeming of Severity Bands
Recommendation: Where the level of severity of a person's infection at Level 3 or more has been established to IBCA's satisfaction in relation to a given year, but it is not known when it reached Level 3 or more, the legislative …
Gov response: The Government acknowledges the concerns that the Inquiry has set out regarding the mechanism for determining the number of years a person with Hepatitis was likely to have spent at particular severity bands when there …
Accepted
In progress
IBI-A-4e — Evidence of Diagnosis Date
Recommendation: Regulation 14(2)(c) be amended to remove the requirement for evidence of the date of diagnosis of Hepatitis B or C. An appropriate redraft to achieve this would be: "where the diagnosis mentioned in sub-paragraph (a) is one of HIV, the …
Gov response: In order to aid processing of claims quicker, the Government has accepted the Inquiry's recommendation to remove the requirement for people with Hepatitis B or C to evidence their date of diagnosis with those infections …
Accepted
In progress
IBI-A-6a — Financial Loss and Care
Recommendation: "x" be removed from the equation set out in Regulation 7.
Gov response: The Inquiry has raised concerns regarding the calculation of past care and financial loss awards for those who choose to continue receiving support scheme payments. The Inquiry has recommended that a formula in the regulations …
Accepted in Part
In progress
IBI-A-6b — Exceptional Loss Evidence
Recommendation: The Cabinet Office consult on whether the evidential requirements for exceptional reduced earnings are likely to prove a barrier to people who have sufficient evidence that their eligibility for such an award could with confidence be established on a balance …
Gov response: The exceptional loss award which is part of the supplementary route provides additional compensation for those infected people who would have received higher pay if it were not for their infection. The Government commits to …
Accepted in Part
In progress
IBI-A-7a — Unethical Research Award
Recommendation: Where there is evidence that an individual was the victim of unethical research practices IBCA should be authorised to make an unethical research practices award to that individual.
Gov response: The issue of unethical research is one of the most shocking areas of this scandal. In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the …
Accepted in Part
In progress
IBI-A-8b — Affected Estates
Recommendation: The Regulations be amended such that where someone who would be an eligible affected person dies between 21 May 2024 and 31 December 2029, their claim does not die with them but becomes part of their estate.
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the Scheme compensates the estates of affected people. The Inquiry originally recommended that it was beyond …
Accepted
In progress
IBI-A-9a — Bereaved Partner Support Scheme
Recommendation: The IBSS cut-off date of 31 March 2025 be reviewed, that the scheme should as soon as possible reinstate support payments to partners bereaved after 31 March 2025 until such time as they receive compensation and that they should have …
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at the 31 March 2025 'cut-off' date for bereaved partners to join an Infected Blood Support Scheme. The …
Accepted
In progress
IR2-3 — Standard of Proof and Automatic Eligibility
Recommendation: As above, save that (a) the last bullet point should read: "eligibility is accepted if the information available points towards eligibility and the opposite cannot be shown to be more likely" and (b) eligibility should be automatic for individuals already …
Gov response: The Government acknowledges the further distress and trauma that can be caused to those applying for compensation, and so the Scheme has been designed to minimise the burden on applicants whilst protecting against fraud. People …
Accepted
Delivered
IR2-4 — Affected Persons Categories
Recommendation: I recommend that the following relevant affected persons should be admitted to the scheme: a) spouses, civil partners and long term cohabitees (for at least one year in the case of the latter) of living or deceased eligible infected persons; …
Gov response: With respect to recommendation 4 of the Second Interim Report, for those who have been affected by this scandal, affected persons will be eligible where their case is linked to that of an eligible infected …
Accepted
Delivered
IR2-6 — Categories of Loss and Award Heads
Recommendation: I recommend that the appropriate award in any case should be composed under the following categories of loss, applicable to both eligible infected and affected persons: a) an Injury Impact Award for past and future physical and mental injury, emotional …
Gov response: With respect to recommendation 6 of the Second Interim Report, the Government has accepted the Inquiry's recommended categories of award, and has therefore designed the Scheme to award compensation to include the following: Injury Impact …
Accepted
Delivered
IR2-7 — No Exemplary Damages but Court Access Preserved
Recommendation: I recommend that there should be no award for exemplary damages, though it should remain open to a claimant to pursue such a claim in the courts irrespective of whether they make a claim on the scheme.
Gov response: There is no award for exemplary damages, as recommended by the Second Interim Report in recommendation 7.
Accepted
Delivered
IR2-8 — Tariff-Based Compensation Framework
Recommendation: I recommend that the Government should approve a scheme setting out a framework of tariff based compensation for eligible infected and affected persons, at rates which broadly take account of but are not limited by current practice in courts and …
Gov response: In line with recommendation 8 of the Second Interim Report, the Scheme will use a tariff-based framework to calculate the amount of compensation payable to those eligible. In practice, this means that compensation will be …
Accepted
Delivered
IR2-9 — Status of Awards and Legal Rights
Recommendation: I recommend that, with reference to the status of awards: a) eligible infected and affected persons should not be required to accept the offer of an award in full and final settlement of any right to pursue legal actions related …
Gov response: In line with recommendations 9 and 10 of the Second Interim Report, acceptance of an award does not require applicants to waive their right to pursue litigation. In defined circumstances, if an infected person's condition …
Accepted
Delivered
IHRD-38 — Multi-Disciplinary Peer Review
Recommendation: Investigations should be subject to multi-disciplinary peer review.
Gov response: Multi-disciplinary review processes incorporated into SAI investigation procedures.
Accepted
Delivered
IHRD-39 — Investigation Team Reconvening
Recommendation: Investigation teams should reconvene after an agreed period to assess both investigation and response.
Gov response: Follow-up review processes established for SAI investigations.
Accepted
Delivered
IHRD-40 — SAI Learning Informing Clinical Audit
Recommendation: Learning and trends identified in SAI investigations should inform programmes of clinical audit.
Gov response: Learning from SAI investigations incorporated into clinical audit programmes.
Accepted
Delivered
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Gov response: Mortality meeting recording and audit procedures implemented.
Accepted
Delivered
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with …
Gov response: Video conferencing facilities provided for multi-Trust mortality meetings.
Accepted
Delivered
IHRD-57 — Clinical Training for Guidelines
Recommendation: Specific clinical training should always accompany the implementation of important clinical guidelines.
Gov response: Training incorporated into clinical guideline implementation processes.
Accepted
Delivered
IHRD-65 — SAI Investigator Training
Recommendation: Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Gov response: SAI investigation training provided to designated investigators.
Accepted
Delivered
IHRD-66 — Time for SAI Learning
Recommendation: Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.
Gov response: Protected time for learning from SAI investigations incorporated into practice.
Accepted
No update 2+ yrs
IHRD-67 — Informing Teaching Authorities
Recommendation: Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.
Gov response: Mechanisms established for informing teaching authorities of relevant investigation findings.
Accepted
Delivered
IHRD-68 — Using Investigations for Training
Recommendation: Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.
Gov response: Information from investigations and complaints assessed for training purposes.
Accepted
Delivered
IHRD-94 — Clinical Negligence Litigation Reform
Recommendation: The interests of patient safety must prevail over the interests engaged in clinical negligence litigation. Such litigation can become an obstacle to openness. A government committee should examine whether clinical negligence litigation as it presently operates might be abolished or …
Gov response: Under consideration. No government committee established to date to examine clinical negligence litigation reform.
Accepted in Part
No update 2+ yrs
F115 — Investigations
Recommendation: Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; Subject matter involving clinically related issues is not capable …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F222 — General Medical Council Systemic investigation where needed
Recommendation: The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F224 — Information sharing
Recommendation: Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F225 — Peer reviews
Recommendation: The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F226 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F227 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F229 — Revalidation
Recommendation: It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F231 — Coordination with internal procedures
Recommendation: It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F232 — Employment liaison officers
Recommendation: The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F44 — Use of information about compliance by regulator from: Media
Recommendation: Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F91 — NHS Litigation Authority Improvement of risk management
Recommendation: The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F92 — NHS Litigation Authority Improvement of risk management
Recommendation: The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F94 — Evidence-based assessment
Recommendation: As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F95 — Information sharing
Recommendation: As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F96 — Information sharing
Recommendation: The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
FP1 — Fingerprint evidence as opinion
Recommendation: Fingerprint evidence should be recognised as opinion evidence, not fact, and those involved in the criminal justice system need to assess it as such on its merits.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP16-18 — Academic study requirement
Recommendation: Expert opinion should be informed by proper academic study of the subject.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP3 — Discontinue certainty claims
Recommendation: Examiners should discontinue reporting conclusions on identification or exclusion with a claim to 100% certainty or on any other basis suggesting that fingerprint evidence is infallible.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP5 — Basis of conclusions
Recommendation: Experts should list all variables considered and state whether the conclusion has been reached through training and personal experience or on any other basis such as statistical analysis.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP53 — Note-taking general practice
Recommendation: Note-taking as to the detail found on analysis and the process of comparison, though not mandatory, should become the general practice for all fingerprint comparison work.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP60 — Disclosure of opinion basis - recording
Recommendation: Experts should record and properly disclose all of the basis of their opinion to enable a court to understand it and the defence to assess it.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP66 — Unable to exclude findings
Recommendation: Before a finding of 'unable to exclude' is led in evidence, careful consideration will require to be given to (a) the types of mark for which such a finding is meaningful and (b) the proper interpretation of the finding.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP9 — Features demonstrable to lay persons
Recommendation: Features on which examiners rely should be demonstrable to a lay person with normal eye sight as observable in the mark.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
FP-COMPLEX — Complex marks examination
Recommendation: Processes should be developed to ensure that complex marks such as those in question are treated differently, by examination by three suitably qualified examiners who reach their conclusion independently, make notes at each stage, and record reasons for their conclusions.
Gov response: Justice Secretary Kenny MacAskill responded on 15 December 2011, the day after the Fingerprint Inquiry report was published. The Scottish Government accepted the inquiry's recommendations. MacAskill stated: "I am confident that the recommendations from this …
Accepted
R38 — Medical record keeping
Recommendation: Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Gov response: Section 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council …
Accepted
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Unknown
PFD Reports (118) — showing 100 most recent
Sidra Aliabase
Concerns: Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.
Overdue
Malik Bunton
Concerns: Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.
Response: The Ministry of Defence has issued further direction and guidance to avoid delays in providing statements for service inquiries. A new process has been directed for all suspected suicides to …
Responded
Anne Dyson
Concerns: Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
Responded
Quy Thi Pham
Concerns: Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women and delaying crucial cancer diagnosis.
Responded
Kenneth Edwards
Concerns: A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Responded
Daisy McCoy
Concerns: Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.
Responded
John Bell
Concerns: Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation or learning review occurred for eight months.
Responded
Alonzo Wood
Concerns: Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual clinical judgment.
Responded
Darren Turner
Concerns: Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.
Responded
Elton Deutekom
Concerns: A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance on historic data, and senior staff delayed emergency response despite prolonged abnormal CTG.
Overdue
Wayne Bayley
Concerns: National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Responded
Terence Clark
Concerns: Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.
Responded
Antony Waring
Concerns: A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and specialist consultation despite known risks.
Responded
Samuel Parkin
Concerns: Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Responded
David Moore
Concerns: A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.
Overdue
James Holgate
Concerns: An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.
Responded
Samantha Shillito
Concerns: A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.
Responded
Tracy Gambrill
Concerns: Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.
Overdue
Thomas Doyle
Concerns: The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.
Responded
Melissa Kerr
Concerns: Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon consultation.
Responded
Kenneth Rippon
Concerns: Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Responded
Ronald Ashdown
Concerns: A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Responded
George Griffiths
Concerns: A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.
Responded
David Nash
Concerns: The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.
Responded
Michael Allen
Concerns: An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior review, which significantly contributed to the patient's deterioration.
Overdue
Teegan Barnard
Concerns: Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust morbidity review after the patient's death.
Responded
Carol Welch
Concerns: Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating neurological findings like subarachnoid haemorrhage, with learning not effectively embedded.
Responded
Quinn Parker
Concerns: Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental information.
Responded
Celia Marsh
Concerns: The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk patients. There's also a lack of robust systems to capture anaphylaxis cases.
Responded
Raymond Griffiths
Concerns: The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
Responded
Billy Longshaw
Concerns: The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.
Overdue
Edward Akroyd
Concerns: No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.
Responded
Alan Hodgson
Concerns: Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.
Overdue
Diana Reay
Concerns: Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.
Overdue
Carl Walters
Concerns: The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
Responded
Brian Jackson
Concerns: Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Overdue
Rhian Roberts
Concerns: Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.
Overdue
Susan Roberts
Concerns: There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.
Responded
Brandon-Robert Collins-Hayward
Concerns: Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.
Responded
William McKibbin
Concerns: Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Responded
Theo Young
Concerns: Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Overdue
Jack Postle
Concerns: The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.
Responded
Harry Richford
Concerns: The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Overdue
John Long
Concerns: Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.
Overdue
Agnes Sansom
Concerns: Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Responded
Ifeoma Onwuka
Concerns: An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Overdue
Clive Miles
Concerns: The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Responded
John Shrosbree
Concerns: Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
Responded
Carl Schmidt
Concerns: The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Responded
Daphne Wigley
Concerns: The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.
Overdue
Alistair McDonald
Concerns: Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was not assessed by a consultant psychiatrist, nor given clear advice for persistent suicidal feelings.
Overdue
Archie Grieves
Concerns: No specific concerns were detailed in the provided text.
Overdue
Jennifer Handy
Concerns: The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Responded
Marcie Tadman
Concerns: No specific matters of concern were detailed in the provided text.
Overdue
Colin Bailey
Concerns: National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
Overdue
Graham Tailby
Concerns: No specific concerns were detailed in the provided text.
Responded
Geoffrey Jackson
Concerns: The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Overdue
Karen Moran
Overdue
Flora Baber
Concerns: Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare providers.
Responded
Peter Saint
Concerns: A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since 2011.
Overdue
Kate Pierce
Concerns: There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.
Responded
Liam Oldsworth
Concerns: The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.
Overdue
Ruth Thompson
Overdue
Anne-Marie James
Concerns: A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health aftercare or family guidance on relapse signs.
Overdue
Catherine Roberts
Overdue
Maurice Macdonnell
Concerns: A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.
Responded
Muriel Brett
Concerns: There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.
Overdue
George Watson
Concerns: Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
Overdue
Diana Ritchie
Responded
Harry Glibbery
Responded
Jean Stockley
Responded
Michael Blow
Overdue
Joshua Knox-Hooke
Responded
Stephen Bird
Concerns: Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
Responded
Leilani Chute
Concerns: Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.
Responded
Kirsty Childs
Concerns: The provided concerns text is incomplete and does not clearly articulate specific safety issues or systemic failures regarding Kirsty Childs' death.
Overdue
Karen Ravenscroft
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
David Aughton
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
Norma Holden
Concerns: The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
Overdue
Nadim Butt
Concerns: The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary consultant-led out-of-hours rota for post-surgery patients was not yet implemented.
Overdue
Edward Paddon-Bramley
Concerns: Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Overdue
Max Haigh
Concerns: Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.
Overdue
Euphemia Aldred
Concerns: The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Euphemia Aldred's death.
Overdue
Vasilis Ktorakis
Concerns: Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing feedback prevented staff learning and improvement.
Responded
Casey Garrett
Concerns: Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.
Responded
Rachel Hollister
Concerns: The provided text describes the circumstances of death but does not explicitly state specific concerns or systemic failures identified by the coroner.
Pending
Jackson Mitchell
Concerns: The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.
Overdue
Monique Whitbread
Concerns: A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.
Overdue
Esther Jones
Concerns: Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
Overdue
Wilfred Aspinwall
Concerns: Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Overdue
Else Harvey-Samuel
Concerns: Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.
Overdue
Frances Bell
Concerns: The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Overdue
Richard Jaeger-Forzard
Concerns: The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Responded
Abiola Dosunmu
Concerns: Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.
Responded
Ann Bennett
Concerns: The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Overdue
Mary Wanya
Concerns: Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Overdue
Paul Ashton
Concerns: There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.
Overdue
Michael Anthony
Concerns: The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP for its prescription.
Overdue
Kerry Jacobs
Concerns: The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Responded
Charles Bradley
Concerns: Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Overdue