Recurance · prevention of future deaths reports
Pre-inquest brief
Governance failure in incident identification
The earlier warning
Elvon Morton · 13 May 2024 · Graeme Irvine, East London
“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”
judiciary.uk/…/elvon-morton-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Chloe Every (25 Oct 2024) · stated timescale: 2025
“BHRUT plan to recruit more learning disability nurses in 2025. They have created pathways to encourage and upskill existing staff due to the shortage of nurses going into learning disability training (RNLD).”
What recurred
- 25 Oct 2024 · Chloe Every · Graeme Irvine
- 12 May 2025 · Kenneth Foster · Graeme Irvine · Identical hazard · confidence 0.90 (high)
- 23 Sept 2025 · Tony Jackson · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.