“Failure of members of staff to understand the concept of confirmation bias”
Dated 24 Sep 2021, from the coroner for South Yorkshire East. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 19 Nov 2021. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated24 Sep 2021
- Deadline19 Nov 2021
- Published on judiciary.uk5 Oct 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNamed in the report as “Doncaster and Bassetlaw NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Nov 2021. A reply may have been sent and not yet published. |
| Health Services Safety Investigations BodyNamed in the report as “Healthcare Safety Investigation Branch” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Nov 2021. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) Failure of members of staff to understand the concept of confirmation bias. (2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices. (3) I am not satisfied the Newsletters had been considered and digested by all staff. (4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training. These are the reasons for my belief that there continues to be a risk.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2021-0321
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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