Kenneth Foster
12 May 2025 · Coroner Graeme Irvine · East London
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. failure to identify incidents
“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”
2. inadequate incident reporting system
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“It is clear that there was no strategic plan or collaboration in governance processes.”
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.”
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Identical hazardConfidence 0.90 · high
Earlier report
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”
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.”
Responses
2025-0231-Response-from-Barts-Health-NHS-Foundation-Trust.pdf ↗· Barts Health NHS Trust
Stated action · 2 days before the inquest
“The Trust acknowledge that Mr [name redacted] family raised serious concerns in their family statement about the care provided to Mr [name redacted] during his final admission to Whipps Cross Hospital. The family concerns were investigated and responded to via the complaints process. The Trust recognise that provision of the complaint response 2 days before the inquest was unacceptable.”
2025-0231-Response-from-The-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care