“The serious incident investigation report in this case was not available in this case…”

The coroner’s concerns

– (1) The serious incident investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with. (2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again. (3) The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services. (4) As a result of the delay in the serious incident Investigation and formulation of an action plan, many of the the identified actions required to remedy these difficulties were still being actioned /completed relatively recently. (5) Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already begun to fade. This was concerning given the identified problem of clinical record keeping at the time of these events. (6) I am concerned that the extensive and continuing delays in investigating serious incidents may lead to further deaths, as lessons cannot be learnt and improvements made in a timely manner. I am also concerned that the quality of such investigations is compromised by the failure to complete memory capture forms and the passage of time before important evidence is secured.

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, 2023-0268

Added to Minute Book

8 Oct 2026

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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