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recurance

Clay Wankiewicz

24 Sept 2021 · Coroner Nicola Mundy · South Yorkshire (East)

The coroner's concerns

  1. 1. confirmation bias

    “Failure of members of staff to understand the concept of confirmation bias”
  2. 2. staff reluctance to adapt

    “A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices”
  3. 3. newsletters not fully considered by staff

    “I am not satisfied the Newsletters had been considered and digested by all staff”
  4. 4. delayed training completion

    “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”
  5. 5. excluded staff from bias training

    “some staff members who were involved in [the deceased]'s management were not prioritised to have that training”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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