Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
93 items
9 sources
3 inquiries
Source spread
Where this theme appears
Flawed mortality reviews has been flagged across 9 independent accountability sources:
10 inquiry recs
42 PFD reports
8 committee recs
5 PPO recs
4 IMB reports
14 IMB recs
5 PHSO decisions
3 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (10)
F278 — Death certification
Recommendation: It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or …
Gov response: 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
F277 — Death certification
Recommendation: National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.
Gov response: 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
F105 — Transparency use and sharing of information
Recommendation: Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
Gov response: 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
40 — Extend medical examiners to stillbirths
Recommendation: Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
39 — Implement medical examiner system
Recommendation: There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
38 — Improve perinatal mortality recording
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
F279 — Death certification
Recommendation: So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient's case or treatment.
Gov response: 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
F276 — Independent medical examiners
Recommendation: Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.
Gov response: 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
F275 — Independent medical examiners
Recommendation: It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
Gov response: 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
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
PFD Reports (42)
John William Wright
Concerns: A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
Overdue
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
Nadine Thurman
Concerns: The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.
Overdue
Janet Goodacre
Concerns: 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.
Response (University Hospitals of Leicester NHS Trust): University Hospitals of Leicester NHS Trust has established a process where each RCA investigation has a named 'Chair', introduced RCA Oversight training for RCA Chairs, and established a new 'Adverse …
Responded
Connor Smith
Concerns: 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.
Response (Prisons Probation Ombudsman): The PPO acknowledges a minor factual inaccuracy in their report, but argues it had no material bearing on the circumstances of the death and that they cannot take further action …
Response (HM Prison and Probation Service): HMP Altcourse has issued a notice to all senior managers who chair Segregation Review Boards, advising them that the documentation for completion at the meeting must not have names entered …
Overdue
Angus West
Concerns: 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.
Response (The Royal College of Midwives): The Royal College of Midwives agrees with the coroner's recommendations to retain and safely store placentas for babies compromised in labour. They provide information regarding current practice, disposal and reasons …
Response (York Teaching Hospital): York Teaching Hospital is instituting a standard operating procedure in respect to retention of placenta following childbirth by September 2016. They have already established that all placentas are routinely inspected …
Responded
Michael Newell
Concerns: 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.
Overdue
Harold Wonfor
Concerns: 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.
Response (Response East Kent NHS Trust): The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full …
Responded
Henry Honour
Concerns: 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.
Overdue
Peter King
Concerns: 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.
Response (East Kent NHS Trust): The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full …
Responded
Thomas Jackson
Concerns: 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.
Response (Department of Health and Social Care): • Officials have made enquiries with a number of bodies regarding routine therapeutic blood monitoring for patients prescribed clozapine. • The NICE guideline CG178, which supports routine monitoring of physical …
Overdue
Malcolm Shaw
Concerns: 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.
Response (Stockport NHS Trust): The Trust has launched a revised programme of investigation training, including in-depth statement gathering and writing sessions, and implemented a checklist for investigation panel meetings to ensure key requirements are …
Responded
Frank Stockton
Concerns: 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.
Overdue
Gloria Mekins
Concerns: 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.
Response (Rossmere Park Care Centre): The care centre disputes the coroner's assertion that staff believed the deceased was choking. Following a Lessons Learned Meeting, they implemented a protocol for staff to follow after a death …
Overdue
Gary Etherington
Concerns: 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.
Response (Oxleas NHS Trust): The Trust has updated its Incident Management Policy and Procedures, implemented a new Serious Incident Team, and provided training on Mental Health Act assessments to address the coroner's concerns. They …
Responded
Wynter Andrews
Concerns: Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.
Response (Nottingham University Hospitals NHS Trust): The Trust has audited compliance with guidelines regarding opiate prescriptions in the latent phase of labour, updated the intrapartum risk assessment document and launched it with staff education, and launched …
Responded
Eddie Coffey
Concerns: 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.
Response (Lister Hospital): The Trust will ensure that when obtaining an independent third-party or independent clinical opinion in the future, this is done on a more formal basis with clear terms of reference. …
Response (Dept. for Health and Social Care): The DHSC expresses condolences and highlights existing NICE guidelines and national initiatives related to maternity care and fetal monitoring. It also notes that HSIB has been made aware of the …
Responded
Norma Lockton
Concerns: 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.
Overdue
Betty Tadman
Concerns: 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.
Response (Medway Maritime Hospital): Medway Maritime Hospital will present the case as a study at a multidisciplinary Grand Round session. The Trust is committed to implementing a "silver trauma" screening system in ED and …
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
Derek Holmes
Concerns: 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.
Response (NHS Tameside and Glossop Integrated Care): NHS Tameside and Glossop Integrated Care acknowledges errors in a root cause analysis and has implemented actions including immediate strategy meetings, training improvements (investigation training, Datix training), and policy/process changes. …
Responded
George Elliott
Concerns: 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.
Response (North Bristol NHS Trust): The Trust acknowledges shortcomings in the investigation report regarding Mr. Elliot's fall and states that the Falls Policy referenced has been replaced with an updated policy in December 2021. They …
Responded
Drew Howe
Concerns: The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Response (Pennine Care NHS Foundation Trust): The Trust will address the coroner's concerns by several actions including; offering awareness sessions, trust wide learning, case reflection with teams and ensuring assessment information is shared between services. They …
Responded
Roger Southwick
Concerns: 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.
Response (Tameside and Glossop Integrated Care NHS Foundation Trust): The Trust already holds daily ward safety huddles to discuss patients at risk of falls, and has a number of existing practices and processes for falls prevention in place. They …
Responded
Francis Barnes
Concerns: 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.
Response (Oxford University Hospitals NHS Foundation Trust): Oxford University Hospitals updated their Mortality Review Policy to include an appendix on cross-system learning responses and established a weekly Patient Safety meeting with the Buckinghamshire, Oxfordshire and Berkshire West …
Responded
Emmanuel Ladapo
Concerns: Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical deterioration, despite prior similar omissions.
Overdue
Charlie Millers
Concerns: 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.
Response (Department of Health and Social Care): The Department of Health and Social Care details several actions and initiatives: NHS England reviews deaths of those detained under the Mental Health Act; the National Confidential Inquiry analyzes inpatient …
Responded
Gordon Long
Concerns: 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.
Overdue
Megan Williams
Concerns: 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.
Response (National Institute for Health and Care Excellence): NICE acknowledges the concerns raised but does not consider any actions from NICE would address the issues.
Response (NHS England): NHS England states that the concerns are local issues for the Trust to address, but that regional colleagues are engaging with the ICB and NHS England will review the Trust's …
Response (East Kent Hospitals): East Kent Hospitals is reinforcing the Acute Abdominal Pain Pathway (AAPP) through monthly teaching sessions and case discussions. The AAPP document includes updated patient risk assessment, and the Hospital Discharge …
Responded
Joan Knight
Concerns: The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
Response (University Hospitals Birmingham NHS Foundation Trust): The trust has disabled multiple methodology coding fields in its Dendrite software, requested specialties use Learning from Deaths Team recommended coding scores, and identified specialties using Dendrite software. It plans …
Responded
Robert Taylor
Concerns: Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
Response (University Hospitals Birmingham NHS): The Lead Nurse for falls has worked with the legal service team to revise the templates used for the nursing witness statement. The Legal Services Team will ensure that specialist …
Responded
June Phillips
Concerns: 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.
Response (Willow Grange Care Home): The care home has implemented a root cause analysis tool, uses body maps and photos for injuries, calls 999 in specific fall scenarios, implemented weekly GP ward rounds with detailed …
Responded
Jean Pike
Concerns: Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Response (Swansea Bay University Health Board): Swansea Bay University Health Board provided additional training to Serious Incident Investigators, focusing on process mapping to improve analysis of clinical input against specified processes, and implemented regular team meetings …
Responded
Renate Mark
Concerns: 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.
Response (Northumbria NHS): The Trust is briefing ward staff on the definitions of 'witnessed' and 'unwitnessed' falls and the importance of accurate terminology and will involve Governance Leads in internal investigations to ensure …
Responded
David Tighe
Concerns: 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.
Response (Oxfordshire University Hospitals NHS Foundation Trust): Oxford University Hospitals NHS Foundation Trust has strengthened mortality review processes by formalising feedback of family concerns and modifying the Serious Judgement Review template to address concerns about scope, focus, …
Responded
Lorraine Parker
Concerns: 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.
Response (Royal Berkshire NHS Foundation Trust): The Trust has deployed additional support to specialties needing strengthened learning from deaths processes, assisted the GMC, removed a surgeon from high-risk procedures, and liaised with private hospitals. They also …
Responded
Etta-Lili Stockwell-Parry
Concerns: 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.
Response (Betsi Cadwaladr University Health Board): Betsi Cadwaladr University Health Board has made immediate safety changes including that investigations across women's and neonatal services will have a single investigation officer and use the framework and templates …
Responded
Karl Dunstan
Concerns: Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Response (Milton Keynes University Hospital NHS Foundation Trust): Milton Keynes University Hospital disputes that a missed D-dimer test more than minimally contributed to the patient's death, asserting the management was reasonable. However, they plan to trial a system …
Responded
Matthew Goldsmith
Concerns: 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.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): Barking, Havering and Redbridge University Hospitals NHS Trust has implemented an action plan to address missed radiological findings, including mandatory training for radiologists, improved peer review processes, and use of …
Responded
Mohan Hothi
Concerns: 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.
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 (Ministry of Defence): The RAF has directed that all suspected suicides will now be subject to an immediate fact-finding investigation, formally brought into the RAF Postvention Suicide Response policy. Further direction and guidance …
Responded
Evie Muir
Concerns: 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.
Response (Mid and South Essex NHS Foundation Trust): The Trust is undertaking a quality improvement program to improve processes for learning from deaths and will allow sharing of learning between teams and across hospital sites. The Rheumatology team …
Responded
Committee Recommendations (8)
#3 — Commission a multilateral development review to report on supported organisations' performance by 2026.
Recommendation: The Government should commission a multilateral development review to consider and report on the performance of the organisations it supports, before the end of 2026. (Recommendation, Paragraph 13)
Gov response: Disagree. 1. The Government is increasing the share of FCDO ODA going to multilateral institutions. This investment will be targetedstrategically to the most effective multilateral organisations in the areas partners consistently say matter most – …
No Published Response
#2 — Multilateral development review urgently needed for understanding ODA commitments and performance.
Recommendation: A multilateral development review is urgently needed to underpin the change in proportion of ODA spent through this channel. The Government needs a clear understanding of its current commitments and the performance of multilateral organisations it supports. (Conclusion, Paragraph 12)
Gov response: Disagree. 1. The Government is increasing the share of FCDO ODA going to multilateral institutions. This investment will be targetedstrategically to the most effective multilateral organisations in the areas partners consistently say matter most – …
No Published Response
#20 —
Recommendation: We therefore recommend that the Government and NHS England & Improvement bring forward the necessary financial and workforce resources required to mandate the independent review of the deaths of all autistic people and people with learning disabilities in inpatient and …
Gov response: · ® This is a very important issue, but we i' do not agree with saying that we 0 must do this. We already look into the reasons why people with a learning disability and …
Under Consideration
#19 —
Recommendation: In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into …
Gov response: · ® This is a very important issue, but we i' do not agree with saying that we 0 must do this. We already look into the reasons why people with a learning disability and …
Under Consideration
#22 —
Recommendation: In the light of starkly disproportionate and tragic data on death rates from coronavirus of disabled people, including shocking figures for deaths of people, including young people, with learning disabilities, there must be a discrete independent inquiry into the causes. …
Gov response: The important job at the moment is keeping people safe from Coronavirus. We will think about looking at what happened during the Coronavirus emergency afterwards.
Under Consideration
#35 — Unknown scale of deaths and serious harms among vulnerable claimants
Recommendation: We remain concerned that the true scale of deaths and serious harms of vulnerable claimants is currently unknown. As set out by the Chief Medical Advisor, we recognise the complexity of these cases and that being in receipt of benefits …
Gov response: Since 2024 the Chief Medical Advisor has been actively involved in all departmental responses to Coroner-issued Prevention of Future Death (PFD) reports. These reports are already part of the public record, reinforcing transparency and accountability. …
Accepted
#11 —
Recommendation: We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, …
Gov response: 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions …
Not Addressed
#10 —
Recommendation: Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have …
Gov response: 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions …
Not Addressed
PPO Death in Custody Recommendations (5)
The Serious Incident Review Group of Manx Care
The Serious Incident Review Group of Manx Care should always complete an investigation following a death in custody.
The Governor at HMP Peterborough
The Governor at HMP Peterborough should ensure that a manager holds a hot debrief promptly after a death in custody and that all those involved in the incident, including healthcare staff, are invited to attend, in line with PSI 64/2011.
The Head of Healthcare, alongside doctors involved in Mr Honnor’s …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s care, should undertake a formal significant event analysis to identify weaknesses in the care provided and learning from these, and share these with all clinicians working in the prison.
The Governor of HMP Birmingham
The Governor should review how effective previous work to educate managers about the risk assessment process and the Graham judgment has been and provide additional measures, including additional training, where necessary.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a robust quality assurance process of reception and FNIP records to ensure that staff are following the agreed processes and recording and considering all risk factors for suicide and self-harm.
IMB Annual Reports (4)
Wymott (2021)
HMP Wymott largely maintained safety during a challenging Covid-19 reporting year (June 2020-May 2021), seeing reductions in self-harm and violence. While staff efforts and some initiatives were commendable, the pandemic exacerbated long-standing issues, particularly with healthcare provision, the prison estate's infrastructure, property loss, and complaints handling. The restricted regime severely limited opportunities for purposeful activity, education, and resettlement, causing significant frustration among prisoners.
PRISON
Key concerns
Standford Hill (2021)
HMP/YOI Standford Hill maintained a well-run, humane prison with a strong emphasis on rehabilitation, despite significant challenges from the Covid-19 pandemic. The Board commended staff dedication and positive prison culture, but raised concerns about healthcare provision following a death in custody, the lack of an internet room, and reliance on external kitchen facilities. The pandemic severely restricted regime activities and purposeful activity, impacting prisoner progression and wellbeing.
PRISON
Key concerns
Bullingdon (2021)
HMP Bullingdon faced significant challenges during the reporting year (July 2020 – June 2021), exacerbated by Covid-19 restrictions which led to extensive in-cell time and impacted various services. The Board noted chronic overcrowding, an increase in self-harm incidents, and persistent issues with staff experience levels and the provision of mental healthcare. Progression and resettlement efforts were hindered by a high turnover of prisoners, predominantly those on remand or serving short sentences, while the effectiveness of drug interception measures remains a concern.
PRISON
Key concerns
Altcourse (2020)
HMP Altcourse maintained safety and humane treatment during the COVID-19 pandemic, with low levels of self-harm and violence. Staff and prisoner morale remained high due to positive staff attitudes and good communication, despite severe regime restrictions. Key concerns include the challenges of housing an aging prison population, delays in mental health transfers, and persistent issues with prisoner property and food quality.
PRISON
Key concerns
IMB Recommendations (14)
Doncaster 2019 – (2019)
All lessons to be learnt from the findings of internal investigations and the reports of the PPO into deaths in custody to be actioned.
Governor / Director
Ford (2021)
The Board is very concerned by the Prisons and Probation Ombudsman (PPO) report into the death in custody in 2020, which criticised the treatment of long-term medical conditions. We appreciate that the healthcare provider has changed since then but it is essential that the protocol is adhered to in all cases. See sections 6.8.1 and 6.8.2.
Governor / Director
Oakwood (2025)
Although the IMB receives the Prisons and Probation Ombudsman PPO final report on deaths in custody, it no longer receives the clinical review which previously came as an annex to the report. Is it possible to allow access to such reports again?
HMPPS
Littlehey (2021)
With the high number of deaths in custody the Board asks whether the Governor will be focussing on the learning points from those that have occurred and, whether she will be addressing the number of trained family liaison officers (FLOs).
Governor / Director
Hewell (2021)
Please conclude the report into the death on 14 June 2018, so that any identified lessons learned may be acted upon.
Other
Bedford (2021)
The interim Prisons and Probation Ombudsman (PPO) reports on two deaths in custody raise some significant issues and we would ask that a clear action plan is put in place in response to the final reports.
Governor / Director
Swaleside (2022)
The Board shares the concerns expressed by the Senior Management Team regarding the number of deaths in custody during the year and appreciates that much investigation is being conducted by the LTHSE into the root causes of these. However, a national investigation is perhaps required to establish either commonality of cause irrespective of prison type or to highlight specific issues …
Ministry of Justice
Altcourse (2022)
The prison was designated a ‘cluster death site’ in October 2021 but no additional support/training was forthcoming from the centre which would have been helpful in identifying any areas for development.
HMPPS
Leeds (2023)
Leeds is designated a ‘cluster site’, due to the numbers of deaths in custody over the past 12-plus months. Who makes the decisions about what actions are required to ensure that the ‘cluster site’ status may be removed?
Governor / Director
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Lowdham Grange (2025)
What is being done to ensure the mistakes and omissions highlighted in the recent Prevention of Future Deaths reports by the Coroner are not repeated?
Governor / Director
Wymott (2021)
How does the prison intend to ensure that the actions identified in the action plan following Prisons and Probation Ombudsman (PPO) reports into deaths in the prison are implemented effectively (see paragraph 4.2.3)?
Governor / Director
Swaleside (2024)
The Board shares the concerns expressed by the SLT that there have again been deaths in custody during the year, though these all appear to be of natural causes.
HMPPS
Swaleside (2023)
The Board shares the concerns expressed by the SLT that there have again been deaths in custody during the year. A thorough investigation is being conducted by the LTHSE into the causes. However, a national investigation is perhaps required to establish either commonality of cause irrespective of prison type and to highlight specific issues relating to particular establishments.
HMPPS
Health Investigations (2)
An independent review of the Independent Investigations for Mental Health … — Rec 3
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the Serious Incident Framework.
north_east_yorkshire
An independent review of the Independent Investigations for Mental Health … — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
north_east_yorkshire
PHSO Casework Decisions (5)
P-001459 — United Lincolnshire Hospitals NHS Trust
Mrs N complains aspects of care hospital staff gave to her husband in the last two months of his life. She believes failings led to his health worsening and could have contributed to his death.
NHS in England
Partly Upheld
Jul 2022
P-003690 — A practice in the Amber Valley area
Ms B complained about the care and treatment the Practice provided her mother during the month prior to her sudden death.
NHS in England
Jul 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complains about the care and treatment her father, Mr D, received from the Trust in April 2020. She says the Trust failed to diagnose and treat him appropriately after surgery, mismanaged his sepsis, overlooked signs of blood clots, and did not refer his case to the coroner despite …
NHS in England
Sep 2025
P-002443 — Hull University Teaching Hospitals NHS Trust
Ms F complains that her daughter had to wait for over 30 hours before being moved to intensive care, that the Trust failed to find the cause of her bleeding and treat it, and that it did not accurately record the cause of her death.
NHS in England
Feb 2024
P-003268 — Portsmouth Hospitals University NHS Trust
Mrs A complains that doctors treated her husband incorrectly when he was in hospital towards the end of his life. She does not accept he had dementia or Parkinson’s disease and believes they missed the real cause of his health problems.
NHS in England
Not Upheld
Jan 2025
LGO / SPSO Decisions (3)
NIPSO-202003319 — Northern Health and Social Care Trust
A woman whose father died in Causeway Hospital after removing his oxygen mask believed he should have been monitored more closely. She also questioned why the Trust did not commission a review into the incident.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
NIPSO-202002627 — Northern Health and Social Care Trust
The Northern Trust failed to act on a woman’s concerns about her mother’s health. This, as well as its failure to properly assess her spinal injury and accurately read the results of an MRI scan, led to her untimely death.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
21-018-958 — Leeds City Council
Summary: We will not investigate this complaint about Mrs Y’s death in a care home, which the family believe was due to choking on meat. We could not say that any fault had caused injustice to Mrs Y and her family, because a coroner found Mrs Y did not die …
LGO (Local Government & …
Adult Care Services
May 2022