Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate incident reporting and review systems
The earlier warning
Elvon Morton · 13 May 2024 · Graeme Irvine, East London
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
judiciary.uk/…/elvon-morton-prevention-of-future-deaths-report
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 12 May 2025 · Kenneth Foster · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Elvon Morton · 13 May 2024
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
Later · Kenneth Foster · 12 May 2025
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
What happened next
No web check of the stated actions has been published for this chain.