Recurring concern

Failure to incorporate relevant clinical history and diagnoses into care decisions

First to latest report 25 Mar 2014 — 27 May 2026

Reports that mention this concern
33
Times this concern has been raised
35
Stated actions linked to this concern
50

What this concern includes

Includes failures in clinical assessment or treatment-planning processes to obtain, consider, document or use relevant previous diagnoses, treatment, available records and information from prior care providers when making care decisions.

What is not included
  • Excludes failures limited to accessing or transferring clinical records when the material unsafe condition is unavailable records rather than failure to incorporate relevant information into the decision.
  • Excludes generic documentation deficiencies where no failure to consider relevant clinical history or diagnoses is identified.
  • Excludes failures to consider family, carer or advocate views unless they are part of a broader failure to incorporate relevant clinical information into the care decision.
  • Excludes condition-specific assessment or treatment pathways where that named condition or system provides the more specific supported boundary.

Reports and published responses 33 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    Peter Frosdick · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to exercise professional curiosity and consider GP information

    Wider context from the report

    “(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol. ”

    Source location

    Peter Frosdick · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. East Sussex

    AI-generated summary

    Justin Peter Gallagher · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain previous medical history

    Wider context from the report

    “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care. ”

    Source location

    Justin Peter Gallagher · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Request community medical records for newly arrived prisoners within one week.

    Verbatim wording from the response

    “The Clinical Reviewer recommended that the Head of Healthcare at HMP Lewes should ensure that the past medical history is obtained for new prisoners with chronic conditions, and that their care should be assigned to a named clinician. I can confirm an action plan was implemented with all actions achieved by 1 April 2017 which included:”

    Source location

    2019-0491-Response-by-NHS-England
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit healthcare-record requests to verify that the records-request process is effective.

    Verbatim wording from the response

    “• an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report I can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019. A CQC focus visit took place on 21 and 22 October 2019 and it was reported to the commissioners that record keeping and care planning in particular had significantly improved with the input of additional resources to support this process.”

    Source location

    2019-0491-Response-by-NHS-England
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Run regular SystmOne reports checking whether newly arrived prisoners’ healthcare records have been requested.

    Verbatim wording from the response

    “• the running of a regular report via SystmOne to ensure that healthcare records have been requested; and”

    Source location

    2019-0491-Response-by-NHS-England
    Page 3 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve prison healthcare data and intelligence collection and enable information-sharing before, during and after incarceration to support continuity of care.

    Verbatim wording from the response

    “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are to:”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.

    Verbatim wording from the response

    “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Gallagher and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 August 2019

    Open published response

  3. Staffordshire South

    AI-generated summary

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate consideration of patient history before clinical meetings

    Wider context from the report

    “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. London Inner South

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inquire into psychiatric history when presentation warrants further inquiry

    Wider context from the report

    “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester West

    AI-generated summary

    Carol Buchanan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to act on relevant clinical history

    Wider context from the report

    “5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately: a. The importance of the history not appreciated upon; b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon; c. Delay in implementing delivery of fluid balance monitoring; and d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms. ”

    Source location

    Carol Buchanan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise Safety Huddle documentation to record family views about patients’ care.

    Verbatim wording from the response

    “I was sorry to hear that the family’s concerns regarding their mother were not appreciated by the medical and nursing teams responsible for Mrs Buchanan’s care. The views of family regarding their relatives’ care are paramount and as a result a significant change in the Trust’s Safety Huddle documentation has been revised to include a section for any family views. This will be highlighted in addition the Fluid Monitoring Policy has been amended to also take account of a family’s views.”

    Source location

    2017-0294-Response-by-Bolton-NHS-Trust
    Page 2 · response
    Published 27 November 2017

    Open published response

  6. Blackpool and the Fylde

    AI-generated summary

    Bernard Cosgrove · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Bernard Cosgrove was admitted to hospital on 28 February 2017 after being observed unresponsive and was discharged to his nursing home on 10 March 2017 with a dislocated right hip joint that had started to become infected. He died at the nursing home on 21 March 2017 from bronchopneumonia, with significant heart disease and hip joint infection contributing to his death. The principal concerns were that the dislocation was not recognised for seven days, that relevant medical-record information was not incorporated into his care, and that patient monitoring and consideration of medical records were insufficient.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider relevant previous medical record entries in subsequent patient care

    Wider context from the report

    “The concerns are: • Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. • Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. • But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death. ”

    Source location

    Bernard Cosgrove · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to incorporate identified clinical findings into subsequent nursing care plans

    Wider context from the report

    “The concerns are: • Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. • Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. • But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death. ”

    Source location

    Bernard Cosgrove · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide ward-based education, updates and reminders supporting professional responsibility for patient care and contemporaneous recordkeeping.

    Verbatim wording from the response

    “The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems. We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes.”

    Source location

    2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
    Page 2 · response
    Published 27 November 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement lessons learned from the internal review of patient care.

    Verbatim wording from the response

    “It is acknowledged that, sadly, the necessity to x-ray Mr Cosgrove’s hip was not acted upon post the recommendation on the 3rd March 2017. The nursing staff continued with Mr Cosgrove’s plan of care until his discharge on the 10th March 2017, this included a strict turning regime given his susceptibility to developing pressure damage, which for a patient like Mr Cosgrove could have been fatal. The Trust cannot, identify why, in Mr Cosgrove’s case, there was no further record or action taken in terms of investigation into the potential findings from the 3rd March 2017 and for this we apologise. However, having undertaken an internal review of Mr Cosgrove’s care, lessons have been learnt and are being implemented.”

    Source location

    2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 27 November 2017

    Open published response

  7. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain and update patients’ risk history and assessment

    Wider context from the report

    “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider continuation of prescribed citalopram

    Wider context from the report

    “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression. Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration. The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this. Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville. ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to recognise prior compliant antidepressant treatment

    Wider context from the report

    “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression. Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration. The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this. Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville. ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The prison is responsible for concern 5 and must provide the response.

    Verbatim wording from the response

    “Response: This concern is a matter for the prison and accordingly, we will leave it for them to respond.”

    Source location

    2016-0196-Response-by-Care-Uk
    Page 1 · response
    Published 19 May 2016

    Open published response

  9. East London

    AI-generated summary

    EMMA LOUISE BRAY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain a proper treatment and medication history from the patient and primary sources

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve the quality of assessment and treatment plans.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  10. Berkshire

    AI-generated summary

    Miss Chandni Nigam · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain relevant history and treatment input from private clinicians

    Wider context from the report

    “(1) During the course of her on-going care, Miss Nigam was being seen by private psychiatrist and psychologist. When she reverted to NHS Mental Health Team Care she still had on-going sessions with the private psychologist. There was an opportunity to gain history and input from the private clinicians as to Miss Nigam’s history, previous treatment and what had been successful and less successful. No attempt to obtain that history or any input from the previous private clinicians appears to have been made. There was an opportunity to obtain helpful and effective historical information that may have assisted in the treatment of Miss Nigam by the Mental Health Team. ”

    Source location

    Miss Chandni Nigam · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026