Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
14 items
1 source
5 inquiries
Source spread
Where this theme appears
Flawed mortality reviews has been flagged across 1 independent accountability source:
14 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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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 …
Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)
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
In progress
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 …
Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)
Gov response: The inquiry says the sudden, unexpected death in infancy and childhood guidance must be updated. I agree. That is now underway.
Accepted
In progress
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 …
Words of: Virginia Bottomley, Secretary of State for Health, in a written answer to Richard Spring MP, House of Commons, 2 November 1994
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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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
In progress
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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
In progress
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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
In progress
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
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
In progress
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