Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Iris Fordham · 5 Oct 2023 · Graeme Irvine, East London
“The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence”
judiciary.uk/…/iris-fordham-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Elvon Morton (13 May 2024) · stated timescale: none stated
“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.”
Stated action 2 · response to Elvon Morton (13 May 2024) · stated timescale: none stated
“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
Stated action 3 · response to Elvon Morton (13 May 2024) · stated timescale: none stated
“Teams will ensure that consultants on call confirm that they have remote access to the electronic healthcare record, this will eliminate the risk that documentation is not completed in relation to critical decisions.”
3 further stated actions are listed on the full chain page.
What recurred
- 13 May 2024 · Elvon Morton · Graeme Irvine · Identical hazard · confidence 0.90 (high)
- 29 Sept 2025 · Mohammad Asghar · Graeme Irvine · Identical hazard · confidence 0.96 (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.”
Later · Mohammad Asghar · 29 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.”
What happened next
No evidence found either way · stated action 1
“Contrast: [](/)”
Key documents - Barts Health NHS Trust · bartshealth.nhs.uk/key-documents
No evidence found does not mean the action did not happen.