Recurring concern

Unreliable communication in district nursing care coordination

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First reported 7 Aug 2013•Latest report 21 May 2025

Definition

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.

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: 12
Individual concerns: 16
Date range: 2013–2025
Stated actions: 14

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2

Royal College of Nursing2

Care Quality Commission1

Cornwall Partnership NHS Foundation Trust1

East London NHS Foundation Trust1

Homerton Healthcare NHS Foundation Trust1

Kent Community Health NHS Foundation Trust1

Lewisham and Greenwich NHS Trust1

London Borough of Lewisham1

Medway Community Healthcare C.I.C.1

Monkstone House1

NHS Greater Manchester Integrated Care Board1

Northern Care Alliance NHS Foundation Trust1

Pennine Care NHS Foundation Trust1

Recipient name withheld1

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.

28 Aug2013
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure of communication between the care home, district nurses and out of hours GP
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Record the substance of telephone conversations with families and professional agencies.
  Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completed
2. Action
  Implement clear, auditable message sheets for out-of-hours district nursing referrals through the Princess of Wales Hospital switchboard.
  Stated by Swansea Bay University Local Health BoardStated completed
3. Action
  Implement SBAR referral and handover documentation for district nursing and out-of-hours GP communication, with staff training on its use.
  Stated by Swansea Bay University Local Health BoardStated completed
1. Action
  Require direct clinician-to-clinician handover of care and verbal communication of outstanding problems during shift changes.
  Stated by Swansea Bay University Local Health BoardStated planned
2. Action
  Disseminate reminders to out-of-hours GPs requiring direct discussion with the clinician accepting responsibility for a patient's care.
  Stated by Swansea Bay University Local Health BoardStated completed
3. Action
  Introduce a Bridgend weekend rota of on-duty district nurse mobile telephone numbers for the out-of-hours GP service.
  Stated by Swansea Bay University Local Health BoardStated planned
4. Action
  Develop a clear out-of-hours escalation process for resolving disputed clinical issues.
  Stated by Swansea Bay University Local Health BoardStated planned
Respondent positions 1
1. Position
  The communication breakdown was between district nurses and the out-of-hours GP service, not Monkstone House and those services.
  Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUDisputes the concern
AI-generated summary

Terrance O’Connell · 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

Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.

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 the care home, district nurses and out of hours GP
Wider context from the report
“(1) There was a communication breakdown between the care home, district nurses and out of hours GP on the 3rd May 2013 resulting in Mr O’Connell not being seen by any clinical staff. ”
Source location
Terrance O’Connell · 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
Record the substance of telephone conversations with families and professional agencies.

Verbatim wording from the response
“1 Telephone calls are now recorded to confirm the substance of all conversations between families and all other professional agencies.”

Source location
2013-0218-Response-by-Gabbandco
Page 3 · response
Published 28 August 2013
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 clear, auditable message sheets for out-of-hours district nursing referrals through the Princess of Wales Hospital switchboard.

Verbatim wording from the response
“The Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for the switchboard staff at the Princess of Wales Hospital to record all of hours requests for District Nurses in greater detail. The SBAR forms will ensure clear, audible records of referrals to the District Nursing Service in the Bridgend Locality, supporting safe, high quality patient care and the ability to review information and audit.”

Source location
2013-0218-Response-by-University-Health-Board
Page 1 · response
Published 28 August 2013
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 SBAR referral and handover documentation for district nursing and out-of-hours GP communication, with staff training on its use.

Verbatim wording from the response
“Issue identified: Need for clarity in communication with out of hours GP service.”

Source location
2013-0218-Response-by-University-Health-Board
Page 9 · response
Published 28 August 2013
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
Require direct clinician-to-clinician handover of care and verbal communication of outstanding problems during shift changes.

Verbatim wording from the response
“████████ Clinical Manager for the GP OOH Service has discussed this case on two occasions with nurse management and agreed that in future all handover of care should be made person to person and not via messages left at switchboard.”

Source location
2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013
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
Disseminate reminders to out-of-hours GPs requiring direct discussion with the clinician accepting responsibility for a patient's care.

Verbatim wording from the response
“████████ has written to all the out of hours GP’s to remind them that they must speak directly to the clinician who they wish to involve in the patient’s care and ensure that responsibility has been passed to that person. It has been pointed out that this procedure must be followed at shift changing times and outstanding problems are communicated verbally and directly to the GP coming on shift.”

Source location
2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013
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
Introduce a Bridgend weekend rota of on-duty district nurse mobile telephone numbers for the out-of-hours GP service.

Verbatim wording from the response
“The District Nurses in Swansea and Neath Port Talbot Locality currently provide the GP OOH Service with a weekend rota of the District Nurse’s on duty mobile telephone numbers. It is planned that this system will be introduced in October 2013, in Bridgend, once the new 24 hour shift pattern is introduced.”

Source location
2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013
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 a clear out-of-hours escalation process for resolving disputed clinical issues.

Verbatim wording from the response
“Issue identified: Lack of process in place to escalate the issue re the dispute between the two clinicians.”

Source location
2013-0218-Response-by-University-Health-Board
Page 10 · response
Published 28 August 2013
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 communication breakdown was between district nurses and the out-of-hours GP service, not Monkstone House and those services.

Verbatim wording from the response
“You have indicated that in your view there was a communication breakdown between the care home, the district nurses and the out of hours GP service on 3rd May 2013 resulting in Mr O’Connell not been seen by any clinical staff. With respect, our clients do not accept that there was a communication problem between the three parties who you have indentified. The communication breakdown (assuming that such was the case) was between the district nurses and the GP out of hours service.”

Source location
2013-0218-Response-by-Gabbandco
Page 1 · response
Published 28 August 2013
Open published response
7 Aug2013
Manchester (West)
Concerns raised1
1. Poor communication by district nursing teams with GPs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jean 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

Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.

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
Poor communication by district nursing teams with GPs
Wider context from the report
“4. Poor communication by the District Nursing Team with the GP ”
Source location
Jean Miller · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of communication between the care home, district nurses and out of hours GP

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Poor communication by district nursing teams with GPs

Actions described in response 7

Respondent positions 1