Mohammad Asghar
29 Sept 2025 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. failure to identify incident
“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. In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
2. lack of patient safety investigation
“Despite concerns being raised by a medical examiner, a coroner's court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred.”
3. misunderstanding of guidance
“Correspondence received from the Trust sent three months after the inquest that seeks to explain why a PSRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS England guidance on what should trigger a patient safety investigation.”
Linked reports
Identical hazardConfidence 0.96 · high
Earlier report
“A failure in governance at the Trust meant that this case was not identified as a serious incident.”
This report
“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.”