Governance failure in incident identification

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2024 → 2025Kenneth Foster7 months after Chloe Every · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a failure in the Trust's governance processes to recognize and report a death as a patient safety incident. The core issue is the same: inadequate identification of incidents through governance mechanisms.

  Chloe Every · 25 Oct 2024

  “Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”

  Check it in the source

  Kenneth Foster · 12 May 2025

  “A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”

  Check it in the source

  Stated action in the response to the earlier report

  “the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Tony Jackson1 year 4 months after Elvon Morton · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports cite a governance failure that prevented the trust from recognizing and investigating a serious patient safety incident. They differ in the specific framework referenced (serious incident vs. Patient Safety Framework) and the cases examined.

  Elvon Morton · 13 May 2024

  “A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”

  Check it in the source

  Tony Jackson · 23 Sept 2025

  “A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”

  Check it in the source

  Stated action in the response to the earlier report

  “A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Tony Jackson11 months after Chloe Every · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe a failure in the trust's governance processes to recognise a death as a patient safety incident requiring investigation. The core concern is the same: inadequate systems for identifying and reporting safety incidents.

  Chloe Every · 25 Oct 2024

  “Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”

  Check it in the source

  Tony Jackson · 23 Sept 2025

  “A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”

  Check it in the source

  Stated action in the response to the earlier report

  “the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”

  Earlier report in the app · Later report in the app