Recurring concern

Unreliable communication in district nursing care coordination

First to latest report 7 Aug 2013 — 21 May 2025

Reports that mention this concern
12
Times this concern has been raised
16
Stated actions linked to this concern
14

What this concern includes

Includes failures of communication or information sharing specifically within district nursing care coordination, including interfaces with care homes, integrated-care teams, GPs and out-of-hours clinical services, where the failure can delay assessment, referral, treatment or support.

What is not included
  • Excludes generic communication failures without a district nursing care-coordination context.
  • Excludes failures confined to the quality of district nursing treatment, staffing, equipment or referral documentation when communication between care providers is not the shared unsafe condition.
  • Excludes communication involving unrelated clinical services or beneficiaries unless district nursing care coordination is directly involved.

Reports and published responses 12 reports

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

  1. Northumberland

    AI-generated summary

    Malcolm Morris · 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

    Malcolm Morris developed lymphoedema after surgery for penile cancer and died on 5 January 2024 after collapsing with right-thigh pain. The report raises concerns about hospitals being unable to electronically refer patients living outside their usual catchment area to community nursing services, resulting in inadequate discharge information and delayed or absent support for wound and catheter care.

    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 transfer comprehensive discharge and ongoing treatment information to community nursing services

    Wider context from the report

    “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service. As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take. Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible. This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents. In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital. My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services. Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community. The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly. ”

    Source location

    Malcolm Morris · 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

    Develop and lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.

    Verbatim wording from the response

    “Over the past three years, NHS England has developed and led ‘The Frontline Digitisation’ (FLD) Programme, which has supported trusts in adopting electronic patient record (EPR) systems, and which nationally supports increased consistency in digital maturity and improves information sharing between and within organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 29 May 2025

    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

    Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.

    Verbatim wording from the response

    “To further support more consistent interoperability across the NHS, NHS England has developed the ‘Booking and Referral Standard’ (BaRS), which is a national framework designed to help digitise and standardise referrals and bookings across care settings, including urgent and emergency care (UEC), general practice, hospital, and community services.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 May 2025

    Open published response

  2. Inner South London

    AI-generated summary

    Naomi SULEYMAN · 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

    Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.

    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 of communication between D2A therapists and District Nurses

    Wider context from the report

    “(2) There was little communication between the therapists from the D2A team and the District Nurses. ”

    Source location

    Naomi SULEYMAN · 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

    Delays in District Nursing assessment after referral

    Wider context from the report

    “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge. This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them. ”

    Source location

    Naomi SULEYMAN · 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

    Conduct further multi-agency discharge events to improve communication and joint working.

    Verbatim wording from the response

    “• A multi-agency discharge event was carried out on 05/03/2025 which tests the systematic approach to discharge processes and further events are planned to improve multi agency communication and ways of working.”

    Source location

    Response from Lewisham and Greenwich NHS Trust and Lewisham Council
    Page 2 · response
    Published 29 January 2025

    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

    Establish and disseminate an escalation and information-sharing pathway across community services, with ongoing monitoring and audit.

    Verbatim wording from the response

    “• There is now an established pathway, for escalation of concerns and information sharing between community services (Podiatry, District nursing and Community therapies/Enablement). This information has been shared across the services and embedded at all levels and will be monitored and audited moving forward.”

    Source location

    Response from Lewisham and Greenwich NHS Trust and Lewisham Council
    Page 3 · response
    Published 29 January 2025

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    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

    Maintain regular Discharge to Assess–District Nursing meetings and a communication champion to oversee information exchange and care-plan adherence.

    Verbatim wording from the response

    “• In response to the report highlighting limited communication between the Discharge to Assess team and District Nurses, regular meetings have already been established between the teams to ensure consistent exchange of patient information. A staff member, or communication champion, has been appointed to oversee this process and ensure that care plans are followed. These communication efforts are being actively monitored and evaluated to confirm their effectiveness in preventing any future issues.”

    Source location

    Response from Lewisham and Greenwich NHS Trust and Lewisham Council
    Page 4 · response
    Published 29 January 2025

    Open published response

  3. Mid Kent and Medway

    AI-generated summary

    Dorothy June MACEY · 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

    Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

    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 share and escalate delayed antibiotic treatment information

    Wider context from the report

    “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”

    Source location

    Dorothy June MACEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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

    Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses

    Wider context from the report

    “1. The Court heard evidence that since the death of Mr Byron the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs. “Unofficial” referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes. The Court heard evidence that such a referral was thought to have occurred in September 2016 but this was not documented anywhere. 2. Likewise if a referral is sent by email there no instruction to staff that such email must be uploaded into the patients records in order for it to be clearly seen by all workers that the patient has been referred. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    John Davies · 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

    John Anthony Davies had Lewy body dementia and Parkinson’s disease and died on 23 October 2016 after deterioration following an infected pressure sore. Concerns included inadequate risk assessment when his care needs changed, poor communication and information sharing, incomplete records, lack of continuity of care, difficulties securing a suitable nursing home placement, and failures relating to pressure-relieving strategies.

    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

    Insufficient communication and information sharing between the care home and District Nursing Team

    Wider context from the report

    “5. There was little evidence of communication and information sharing between the care home and the District Nursing Team ”

    Source location

    John Davies · Prevention of Future Deaths report
    Page 1 · 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 involve the District Nursing Team in discussions when residents’ status changed

    Wider context from the report

    “2. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions. ”

    Source location

    John Davies · 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

    Appoint a Named Nurse for the residential home.

    Verbatim wording from the response

    “A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.”

    Source location

    2017-0138-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 10 July 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

    Hold monthly residential-home care meetings and share key information at District Nursing Time Team meetings.

    Verbatim wording from the response

    “A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.”

    Source location

    2017-0138-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response

  6. Inner North London

    AI-generated summary

    Christiana Pelle · 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

    Christiana Pelle developed a grade 4 sacral pressure ulcer while living at home under the care of community nursing and a planned care package. The ulcer became infected, and she later died in hospital after contracting pneumonia while receiving inpatient treatment. The principal concerns were unclear guidance about when nurses should involve a GP and inadequate systems for sharing information and escalating concerns between community nursing, other agencies, and the care provider.

    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

    Lack of a clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency

    Wider context from the report

    “(3) The lack of a clearly understood system for communicating concerns and/or other relevant information between the Community District Nurses Team and the care provider agency for a community patient. ”

    Source location

    Christiana Pelle · 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

    Absence of a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner agencies

    Wider context from the report

    “(2) An ongoing absence of any / any clearly understood system for sharing relevant information relating to a community patient and/or escalating concerns about the quality of the care they were receiving, between Homerton’s Community District Nursing Team and other partner agencies involved - in this instance the Community Mental Health Team from the East London NHS Foundation Trust’s City and Hackney Mental Health Care for Older People and the London Borough of Hackney’s Integrated Independence Team; ”

    Source location

    Christiana Pelle · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Cornwall and Isles of Scilly

    AI-generated summary

    Dorothea Jean Parr · 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

    Dorothea Parr fell from a newly delivered electric riser-recliner chair at home on 21 March 2016, sustained a fractured neck of femur, and died of pneumonia on 28 March 2016. The report raised concerns that the chair was delivered without notifying her family, carers, or district nurses, limiting opportunities for training and risk assessment. It also identified a lack of formal procedures for notifying district nurses about falls, changes in presentation, or new equipment.

    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

    Lack of formal protocols for notifying district nurses of falls or changes in fall risk

    Wider context from the report

    “The District Nurse Manger explained that it was the role of the District Nurses to carry out the Falls Risk Assessment for clients living in the community at risk of falling. The District Nurses were very dependent on other agencies to inform them of falls or changes to the risk of falls e.g. the delivery of the electric chair or changes in presentation which increase the risk of falls e.g. confusion. In this case District nurses were not informed of the fall on 21st March from the new electric chair and no requirement for this to be done and so there was a lost opportunity to provide input – which in this case could have been to deactivate the electric armchair while the carers were not present. Although there were informal procedures in place for district nurse notification, there were no formal protocols or procedures in place. ”

    Source location

    Dorothea Jean Parr · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Central and South East Kent

    AI-generated summary

    Michael Longley · 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

    Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.

    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 of effective oral and written communication between integrated care and district nursing services

    Wider context from the report

    “I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place. ”

    Source location

    Michael Longley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Milton Keynes

    AI-generated summary

    Doris Phoebe Miller · 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 circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.

    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

    Lack of an effective communication system between GP surgeries and district nurses

    Wider context from the report

    “(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses. Again this gives rise to a concern that lives may be at risk. ”

    Source location

    Doris Phoebe Miller · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Dorothy Townley · 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

    Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.

    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 of District Nurses and the GP to communicate and coordinate wound care visits

    Wider context from the report

    “1. There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased’s condition was and what was required on visits. There was no consideration given to carrying out joint visits, no communication as to how Mrs Townley’s wound could be examined if there were no dressings available. ”

    Source location

    Dorothy Townley · 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

    Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests

    Wider context from the report

    “5. There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests. It was assumed by the GP that his request for a blood test would be treated as urgent and done that day (on 10th); the District Nurses indicated it would only be carried out as ‘urgent’ if requested. ”

    Source location

    Dorothy Townley · Prevention of Future Deaths report
    Page 2 · 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