Recurring concern

Failure to incorporate relevant clinical history and diagnoses into care decisions

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First reported 25 Mar 2014•Latest report 27 May 2026

Definition

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.

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
33

Distinct published reports

Individual concerns
35

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
50

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England5
Department of Health and Social Care3
Essex Partnership University NHS Foundation Trust2
Ministry of Justice2
North East London NHS Foundation Trust2
Northern Care Alliance NHS Foundation Trust2
Alternative Futures Group Limited1
Berkshire Healthcare NHS Foundation Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Calderdale and Huddersfield NHS Foundation Trust1
Care UK1
Central and North West London NHS Foundation Trust1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Curaleaf Clinic1
Cygnet Health Care Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Kenneth John WILLIAMS · 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

    Kenneth John Williams was admitted with shortness of breath and was diagnosed with tension pneumothorax, leading to insertion of a chest drain. The report states that the diagnosis was incorrect, the drain ruptured a pulmonary bulla and caused bleeding, and concerns included reviewing previous imaging and medical history and involving the respiratory team before and after chest-drain insertion.

    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 previous radiology, medical history and medication before invasive procedures

    Wider context from the report

    “1. Action is required to ensure that previous radiology, patients medical history and medication is always considered before a chest drain insertion or any invasive procedure is undertaken. ”

    Source location

    Kenneth John WILLIAMS · 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

    Use an introduced medical proforma requiring clerking staff to record patients’ medical history and medication.

    Verbatim wording from the response

    “a. Medical Proforma”

    Source location

    2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 30 March 2015

    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

    Deliver chest-drain training that reinforces reviewing historical radiology, medical history and medication and involving the respiratory team in patient care.

    Verbatim wording from the response

    “b. Training”

    Source location

    2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 30 March 2015

    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 adult transfer and four-hour-plan checklists requiring handover teams to document medications and consider historical radiology.

    Verbatim wording from the response

    “4. Action is required to ensure a patient’s previous medical history, historical imaging and medications are always reviewed anew by any subsequent medical team receiving the patient from Accident and Emergency.”

    Source location

    2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 30 March 2015

    Open published response
  2. Suffolk

    AI-generated summary

    Redmond Johnson · 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

    Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care 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 relevant medical information for care planning during initial reception assessment

    Wider context from the report

    “(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison service. ”

    Source location

    Redmond Johnson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester West

    AI-generated summary

    Margaret Walker · 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

    Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

    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

    Delays in obtaining patients’ previous diabetes medication regimes

    Wider context from the report

    “(1) Following Mrs Walker’s admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012. When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed. ”

    Source location

    Margaret Walker · 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

    Issue further guidance clarifying medicines reconciliation responsibilities.

    Verbatim wording from the response

    “The Trust recognises the vital importance of the recording and sharing of accurate information with regard to medication. This is covered within our core training programme on our medicines policy. As a result of this case we have reviewed our policy and processes and will be issuing further guidance to raise awareness of the medicines reconciliation process and particularly the specific responsibilities of staff with regard to this.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    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

    Provide Medicines Management Team access to electronic Summary Care Records.

    Verbatim wording from the response

    “Your letter states that Mrs Walker was admitted on 4 March 2012; however I would like to confirm that Mrs Walker was admitted as a detained patient on 4 August 2012. I note your concerns with the apparent delay in obtaining an accurate medication regime. 6 August 2012 was a Monday and while it was a significant delay (up to 48-hours after admission), it was the earliest possibility at that time for obtaining GP practice held information needed to complement other information sources to establish an accurate medication regime. Recently members of the Medicines Management Team have gained access to the electronic Summary Care Record for patients; this links to GP practices and provides access to the”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    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

    Include routine Summary Care Record access in the new clinical IT system work plan.

    Verbatim wording from the response

    “Routine access to the Summary Care Record is included in the work plan for the Trust’s new Clinical IT system (RiO). Specifically this will improve medicines reconciliation out of routine working hours.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 25 March 2014

    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 regular auditing and reporting of medicines reconciliation failures.

    Verbatim wording from the response

    “The Medicines Management Team provide services on our in-patient wards daily (Monday-Friday) to support a number of functions including medicines reconciliation. The team’s work is audited regularly and the accuracy of their work is assured. The Trust has developed and put in place a process to regularly audit and to report any failings in the medicines reconciliation process.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 25 March 2014

    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

    The admission date was 4 August 2012, and obtaining GP medication information on 6 August was the earliest possibility at that time.

    Verbatim wording from the response

    “Your letter states that Mrs Walker was admitted on 4 March 2012; however I would like to confirm that Mrs Walker was admitted as a detained patient on 4 August 2012. I note your concerns with the apparent delay in obtaining an accurate medication regime. 6 August 2012 was a Monday and while it was a significant delay (up to 48-hours after admission), it was the earliest possibility at that time for obtaining GP practice held information needed to complement other information sources to establish an accurate medication regime. Recently members of the Medicines Management Team have gained access to the electronic Summary Care Record for patients; this links to GP practices and provides access to the”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    Open published response
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Data last updated 7 September 2026