Misleading Information to Coroner
Concerns regarding a local council providing potentially misleading or incomplete information to a coroner about a death.
64 items
8 sources
3 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
73match
ETI-20 - Prohibition on Misleading Reports from ALEOs
The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm's-length external organisation (ALEO) wholly owned by the local authority that is the promoter and owner of the project, should not submit to the local authority information that is deceptive or reports that are misleading either...
Matched on
terms: information, misleading
PFD report
69match
Darren Goddard
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Matched on
terms: information, misleading
PPO recommendation
69match
The Governor
The Governor should ensure that information published on social media about a prisoner’s death is appropriate, accurate and that the nature of the death is not revealed until confirmed by HM Coroner.
Matched on
terms: coroner, information
PFD report
61match
Timothy Clayton
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Matched on
terms: coroner
PFD report
61match
Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Matched on
terms: misleading
PFD report
57match
Alex Blake
Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Matched on
classifier match
IMB recommendation
52match
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Matched on
terms: coroner
Inquiry recommendation
52match
ETI-21 - Duty of Officials to Councillors
Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to provide accurate reports to councillors to enable them to take informed decisions based upon the reality of the situation. Such reports should not be misleading either by the...
Matched on
terms: misleading
PHSO casework decision
51match
P-003908 - Epsom and St Helier University Hospitals NHS Trust
Dr U complains about the care and treatment her son received from a nurse at the Trust. She states the nurse gave misleading and inaccurate information about her son during meetings and failed to consider his best interests.
Matched on
terms: information, misleading
Committee recommendation
51match
#8 - First Report - Direct-to-consumer genomic testing
Several contributors to this inquiry expressed concern that the information provided to consumers before and after using a direct-to-consumer genomic test, as well as the advertising used to market direct-to-consumer genomic tests, did not do enough to address public misconceptions of the capability of these tests and clarify the clinical utility of the results generated. Even where advertising...
Matched on
terms: information, misleading
LGO / SPSO decision
50match
21-018-329 - Surrey County Council
Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. Further investigation on this point will not lead...
Matched on
terms: coroner, information
PFD report
49match
Marcus McGuire
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Matched on
classifier match
Inquiry recommendation
48match
30 - National protocol on duties relating to inquests
A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to...
Matched on
terms: coroner
Committee recommendation
48match
#11 - 1st Report - The Coroner Service
The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient by themselves to prevent large multi-handed inquests, where individuals’ and organisations’ reputations are at stake, from becoming adversarial.
Matched on
terms: coroner
LGO / SPSO decision
47match
21-011-697 - Surrey County Council
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
Matched on
terms: coroner
PHSO casework decision
47match
P-004714 - University Hospitals Birmingham NHS Foundation Trust
Mr A complains while his father, Mr S, was in University Hospitals Birmingham NHS Foundation Trust (the Trust), he was sexually assaulted by another patient while the staff knew the patient posed a risk. He also complains in the Trust response, it supplied false and misleading information.
Matched on
terms: information, misleading
LGO / SPSO decision
46match
25-011-009 - London Borough of Lambeth
Summary: We will not exercise discretion to investigate this complaint about the Council’s officers giving misleading information to the BBC in a broadcast in July 2024. This complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest that Mr X could not have complained to us sooner.
Matched on
terms: information, misleading
PFD report
45match
Roy Travers
There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.
Matched on
classifier match
Committee recommendation
44match
#9 - 1st Report - The Coroner Service
Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We encourage the new Chief Coroner to strengthen guidance and training on disclosure and pre-inquest reviews, emphasising to coroners...
Matched on
terms: coroner
LGO / SPSO decision
43match
21-007-703 - West Northamptonshire Council
Summary: Mr B says the Council misled the Planning Committee which influenced its decision to grant planning permission. Although officers failed to correct one piece of information at the Committee meeting there is no evidence this affected the final decision.
Matched on
terms: information
LGO / SPSO decision
43match
22-006-656 - London Borough of Croydon
Ms X complains about the council staff misleading the criminal justice system.
Matched on
terms: misleading
IMB recommendation
42match
Ford (2020)
Rehabilitation should be at the forefront of policy decisions relating to the open estate and your department’s handling of the Coronavirus Job Retention Scheme (“furlough”) was deplorable. Conflicting and misleading information has almost certainly led to some men leaving the prison system disadvantaged by significant amounts of money with which to re-enter the community at a time when...
Matched on
terms: information, misleading
Committee recommendation
39match
#11 - First report - Missing in action: UK leadership and the withdrawal from Afghanistan
The FCDO has repeatedly given us answers that, in our judgement, are at best intentionally evasive, and often deliberately misleading. On Nowzad, they only admitted that the case had been in any way unusual when faced with the evidence of whistleblowers. At best, the Permanent Under-Secretary displayed a worrying lack of knowledge of the department he leads, and...
Matched on
terms: misleading
PHSO casework decision
39match
P-001720 - A practice in the Wirral area
Mr O complains the Practice gave him wrong information about his test results and about its planned course of treatment.
Matched on
terms: information
PHSO casework decision
39match
P-002626 - A practice in the North Yorkshire area
Mrs N complains that two organisations provided incorrect information to a mental health tribunal.
Matched on
terms: information
PHSO casework decision
39match
P-004230 - University Hospitals Birmingham NHS Foundation Trust
Mrs H complains about the treatment she received from University Hospitals Birmingham NHS Foundation Trust (the Trust). She says in 2016 she had a biopsy on her right lung, during the procedure the surgeon damaged her lung then the Trust provided inaccurate information in its response letter about who completed the surgery.
Matched on
terms: information
PHSO casework decision
39match
P-003153 - A practice in the Oadby and Wigston area
Mr A complains the Practice failed to visit his brother after his discharge from hospital in October 2022 until after he died in December 2022. Mr A also says the Practice failed to record appropriate information when certifying his brother’s death.
Matched on
terms: information
PHSO casework decision
39match
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 his death following major procedures.
Matched on
terms: coroner
PHSO casework decision
38match
P-002056 - A dental practice in the Croydon area
Mrs O complains the Practice gave her misleading information before she had treatment. She says if she had known the truth, she would not have gone ahead with the treatment.
Matched on
terms: information, misleading
Inquiry recommendation
36match
R68 - Consultant involvement in death certificates
Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in completion of the death certificate wherever practicable.
Matched on
classifier match
IMB recommendation
36match
Wandsworth (2024)
In the past year, the IMB was not always informed of major incidents, particularly Deaths in Custody. Can you assure us that you will put a process in place to rectify this?
Matched on
classifier match
Committee recommendation
35match
#22 - Sixth Report - Stolen years: combatting state hostage diplomacy
UK nationals have been let down by the information shared by Ministers— actions which were counterproductive and may have contributed to less favourable conditions for an earlier release. Coherence and accuracy are vital not only in fairness to the families involved, but also to send the message to countries that may consider using detainees as leverage, that the...
Matched on
terms: information
PHSO casework decision
35match
P-003443 - Sandwell and West Birmingham Hospitals NHS Trust
Mrs A complains that in October 2022 the Trust gave confusing information about her husband’s diagnosis, did not drain his kidneys and gave him oral morphine which caused his organs to shut down.
Matched on
terms: information
PHSO casework decision
34match
P-004707 - A practice in the Chesterfield area
Mr L complains about aspects of care provided to him by a Practice in the Derbyshire area. He complains the Practice did not provide clear information regarding why only part of his skin condition was recorded on his records, a doctor at the Practice deliberately misled him during two consultations and the Practice lied in its response.
Matched on
terms: information
PHSO casework decision
34match
P-004147 - Lancashire Teaching Hospitals NHS Foundation Trust
Miss U has raised concerns about the care her father, Mr U, received from the Trust. She highlights delays in administering aspirin following his stroke, inconsistent information about his diagnosis, an undocumented early withdrawal from an induced coma, and conflicting accounts provided during treatment and in the Trust’s complaint response.
Matched on
terms: information
PHSO casework decision
32match
P-003667 - South Tyneside and Sunderland NHS Foundation Trust
Mrs O complains that between 2017 and 2023 the Trust failed to inform her husband that his prostate cancer diagnosis was life-limiting and untreatable.
Matched on
classifier match
PPO recommendation
31match
The Governor of The Mount
The Governor of The Mount should ensure that all evidence, including electronic evidence, relevant to a death in custody is retained and made available to the PPO in line with PSI 58/2010.
Matched on
classifier match
PHSO casework decision
31match
P-004785 - A practice in the Torbay area
Mr A complains a Practice in Paignton incorrectly completed his father’s death certificate, did not provide the amended certificate without cost and did not deal with his complaint in line with its own complaint procedure.
Matched on
classifier match
PHSO casework decision
31match
P-004132 - Oxford University Hospitals NHS Foundation Trust
Dr A complains about aspects of care and treatment her mother, Mrs A, received when she choked on her food at the Trust. She is also concerned about how the Trust investigated the incident and completed the death certificate.
Matched on
classifier match
PHSO casework decision
30match
P-003062 - Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complains the Trust discharged her uncle inappropriately and without a zimmer frame, which resulted in him being readmitted the same day. She also complains the Trust completed a falls assessment incorrectly and it provided her with inaccurate information about his mobility.
Matched on
terms: information
Committee recommendation
27match
#2 - Seventh report - Parliamentary and Health Service Ombudsman Scrutiny 2019–20
In May 2020, the PHSO reported to the Committee that it had experienced an increase of 13 per cent in demand compared to the previous financial year. Due to the introduction of a new digital casework management system, comparisons between years were not possible. This means that the 13 per cent figure cannot be evidenced. The PHSO made...
Matched on
classifier match
Committee recommendation
27match
#22 - Sixth Report - Parliamentary and Health Service Ombudsman Scrutiny 2021–22
The Committee was disappointed to learn that some of the data provided by the PHSO to inform the Committee’s PHSO Scrutiny 2020–21 Report had been revised unjustifiably ahead of this year’s inquiry, preventing easy comparability between reports. For the Committee to accurately fulfil its responsibilities to assess the performance of the PHSO, it is vital that the PHSO...
Matched on
classifier match
Article 2 learning point
27match
TA — HMP Chelmsford - LP 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
Matched on
classifier match
Article 2 learning point
27match
Mr Adakite — HMP Birmingham - LP 18
The list of documents to be retained as set out in PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults where an independent investigation will be necessary should mirror that in PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others (Safer Custody).
Matched on
classifier match
Article 2 learning point
27match
Mr Adakite — HMP Birmingham - LP 17
All relevant documentation relating to a prisoner following an incident that may result in an investigation under Article 2 should be promptly secured.
Matched on
classifier match
PHSO casework decision
27match
P-004371 - Lewisham and Greenwich NHS Trust
Mrs E complains about the care the Trust provided her father between March and April 2022. She says it delayed scanning to identify his cancer had spread, delayed moving him to palliative care and discharging him, asked her and her brother to take a COVID-19 test and falsely claimed to have sent medication to his home by taxi.
Matched on
classifier match
IMB recommendation
27match
Lancaster Farms (2023)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody or the use of the special cell, are implemented. And that the Board receives responses to issues it raises in its weekly reports.
Matched on
classifier match
Committee recommendation
26match
#5 - 5th Report - Maccabi Tel Aviv fan ban
Former Chief Constable Guildford was not informed ahead of giving oral evidence on 6 January that Microsoft Copilot AI had been used to generate the erroneous information about a match between West Ham and Maccabi Tel Aviv. On this basis we can only conclude that the former Chief Constable did not intentionally mislead the Committee. However, by 6...
Matched on
terms: information
PHSO casework decision
26match
P-003894 - The Royal Wolverhampton NHS Trust
Mr R complains about the Trust's care and treatment of his late wife from 2018. He says it did not give his wife or daughter genetic testing, it recorded his wife's cancer incorrectly on an official register, it did not give him information he asked for and its investigation into what happened was not done properly.
Matched on
terms: information
PHSO casework decision
23match
P-001218 - Children and Family Court Advisory and Support Service
Mr A complained that Cafcass incorrectly told a court that he had been convicted of assaulting his ex-wife, which he says did not happen.
Matched on
classifier match