Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
93 items
9 sources
3 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
Joan Knight
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
Matched on
terms: flawed, mortality, review
PFD report
73match
Michael Newell
Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.
Matched on
terms: mortality, review
PFD report
73match
Malik Bunton
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.
Matched on
terms: flawed, review
Inquiry recommendation
73match
38 - Improve perinatal mortality recording
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems...
Matched on
terms: mortality, review
PFD report
65match
Thomas Jackson
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.
Matched on
terms: review
PFD report
65match
Norma Lockton
The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical assistance and an inadequate post-death review.
Matched on
terms: review
PFD report
65match
Charlie Millers
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent oversight for rectifying systemic issues.
Matched on
terms: review
PFD report
65match
Renate Mark
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for high-risk patients. Inadequate scrutiny of witness statements hinders learning.
Matched on
terms: flawed
PFD report
65match
Evie Muir
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.
Matched on
terms: review
Committee recommendation
62match
#3 - Commission a multilateral development review to report on supported organisations' performance by 2026.
The Government should commission a multilateral development review to consider and report on the performance of the organisations it supports, before the end of 2026. (Recommendation, Paragraph 13)
Matched on
terms: review
Committee recommendation
62match
#2 - Multilateral development review urgently needed for understanding ODA commitments and performance.
A multilateral development review is urgently needed to underpin the change in proportion of ODA spent through this channel. The Government needs a clear understanding of its current commitments and the performance of multilateral organisations it supports. (Conclusion, Paragraph 12)
Matched on
terms: review
PFD report
61match
Connor Smith
An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder learning from incidents.
Matched on
terms: review
PFD report
61match
Malcolm Shaw
A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.
Matched on
terms: flawed
PFD report
61match
Billy Longshaw
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.
Matched on
terms: flawed
PFD report
61match
Etta-Lili Stockwell-Parry
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Matched on
classifier match
PPO recommendation
61match
The Serious Incident Review Group of Manx Care
The Serious Incident Review Group of Manx Care should always complete an investigation following a death in custody.
Matched on
terms: review
PFD report
57match
Nadine Thurman
The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.
Matched on
terms: flawed
PFD report
57match
Janet Goodacre
The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.
Matched on
terms: flawed
PFD report
57match
Wynter Andrews
Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.
Matched on
classifier match
PFD report
57match
Francis Barnes
The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.
Matched on
classifier match
PFD report
57match
Megan Williams
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Matched on
terms: flawed
PFD report
57match
David Tighe
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
Matched on
terms: review
PFD report
57match
Matthew Goldsmith
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Matched on
terms: review
PFD report
53match
Harold Wonfor
Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.
Matched on
classifier match
PFD report
53match
Henry Honour
Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were misused, and no protective measures were implemented post-fall.
Matched on
classifier match
PFD report
53match
Peter King
Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.
Matched on
classifier match
PFD report
53match
George Elliott
The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and compromised patient safety.
Matched on
classifier match
PFD report
53match
Drew Howe
The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Matched on
classifier match
Inquiry recommendation
52match
F105 - Transparency use and sharing of information
Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
Matched on
terms: mortality
Inquiry recommendation
52match
40 - Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning the occasional need for inquests in individual cases, including deaths following neonatal transfer. Action: the Department of Health.
Matched on
terms: review
Inquiry recommendation
52match
39 - Implement medical examiner system
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and...
Matched on
terms: review
Committee recommendation
52match
#20 - Fifth Report - The treatment of autistic people and people with learning disabilities
We therefore recommend that the Government and NHS England & Improvement bring forward the necessary financial and workforce resources required to mandate the independent review of the deaths of all autistic people and people with learning disabilities in inpatient and community settings, and ensure there is a structured way to make sure any learning that emerges is disseminated...
Matched on
terms: review
Committee recommendation
52match
#19 - Fifth Report - The treatment of autistic people and people with learning disabilities
In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into such deaths. Of even greater concern is that in some cases, the poor treatment of autistic people and...
Matched on
terms: review
PFD report
49match
Ann Bennett
The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Matched on
classifier match
PFD report
49match
Angus West
The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.
Matched on
classifier match
PFD report
49match
Gary Etherington
Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.
Matched on
classifier match
PFD report
49match
Betty Tadman
Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.
Matched on
classifier match
PFD report
49match
Derek Holmes
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's "moderate" harm grading was not revisited despite its contribution to the patient's death.
Matched on
classifier match
PFD report
49match
Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.
Matched on
classifier match
PFD report
49match
Robert Taylor
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
Matched on
classifier match
PFD report
49match
June Phillips
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.
Matched on
classifier match
PFD report
49match
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon also remain unaddressed.
Matched on
classifier match
PFD report
49match
Mohan Hothi
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Matched on
classifier match
IMB recommendation
48match
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?
Matched on
terms: review
Inquiry recommendation
48match
LAMI-5 - National Agency to conduct or oversee and publish serious child case reviews
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 a child known to the services. This task will be undertaken through the regional offices of the Agency...
Matched on
terms: review
PFD report
45match
John William Wright
A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
Matched on
classifier match
PFD report
45match
Frank Stockton
Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.
Matched on
classifier match
PFD report
45match
Gloria Mekins
A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.
Matched on
classifier match
PFD report
45match
Eddie Coffey
The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training and the use of incorrect guidelines in maternity units.
Matched on
classifier match
PFD report
45match
Roger Southwick
The report identifies failures to accurately complete a Falls Risk Assessment and to reassess the risk after family members reported the deceased's compromised mobility; the Trust's Investigation Report also failed to address these issues.
Matched on
classifier match