Recurring concern

Inadequate informed-consent processes for medical treatment

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First reported 1 Jul 2014•Latest report 28 Dec 2025

Definition

What this concern includes

Includes failures of medical-treatment consent processes, including initiation, information about material risks, time for consideration, consistency of procedure, assessment of consent and documentation, where the failure is directly tied to obtaining valid informed consent.

Not included

  • Excludes legal-status or detention transfers that do not concern consent to medical treatment.
  • Excludes general communication, training, documentation or staffing deficiencies unless they are directly tied to the medical-treatment consent process.
  • Excludes clinical assessment or treatment-selection failures that do not concern obtaining or recording informed consent.
Reports
31

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
56

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.

Department of Health and Social Care7
Care Quality Commission2
General Medical Council2
Mid Yorkshire Teaching NHS Trust2
Royal College of Radiologists2
University Hospitals Sussex NHS Foundation Trust2
Aden Court Care Home1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Association Of Anaesthetists (Great Britain & Ireland)1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Birmingham Women'S and Children'S NHS Foundation Trust1
Bradford Teaching Hospitals NHS Foundation Trust1
British Society For Dermatological Surgery1
Circle Health Group 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. Newcastle upon Tyne

    AI-generated summary

    Maia Hazel Ann Strachan · 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

    Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.

    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 provide advice and explanations for informed pregnancy and delivery decisions

    Wider context from the report

    “(3) Joint Decision Making: - Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making. The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol. ”

    Source location

    Maia Hazel Ann Strachan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Surrey

    AI-generated summary

    Mrs Alice Doris Dixon · 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

    Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

    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 record known information about previous contrast exposure on the consent form

    Wider context from the report

    “6. Part of the consent form about previous contrast was left blank and although the RCA had the information before the scan it was not noted. ”

    Source location

    Mrs Alice Doris Dixon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. City of London

    AI-generated summary

    Marian Hoskins · 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

    Marian Hoskins underwent pressure wire testing after a myocardial infarction and coronary stenting, during which an artery was dissected and she subsequently developed a ventricular septal defect. Attempts to repair the defect were unsuccessful or incomplete, and she died from multi-organ failure on 11 January 2017. The principal concern was insufficient discussion of alternative investigations and the absence of a clear system to ensure informed consent was obtained before admission for the procedure.

    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 outpatient access for informed-consent advice and discussion

    Wider context from the report

    “From the evidence I heard it was apparent that the insufficient discussion with Mrs Hoskins about the investigatory options resulted, in large part at least, from the absence of a clear system and process designed to ensure that full and informed consent is obtained. In particular, the advice and decision making about the pressure wire testing was made (in principle at least) at about the time of her initial percutaneous stenting in October 2016 and without sufficient subsequent out-patient access to advice and discussion. Prior to the conclusion of the Inquest I received a statement dated 21 November 2018 from ████████, Director of Quality and Safety. ████████ stated that the Trust has started a “major quality improvement project” to improve the process of gaining informed consent and he set out details of steps which have already been taken and those planned. In paragraph 10 of the statement it is noted that informed consent is a process that is undertaken over time and that the Trust’s current process does not include informed consent being obtained prior to the patient being admitted for a specific procedure. I am concerned that the insufficiency of the process in the Deceased’s case resulted largely from the absence /insufficiency of outpatient contact to enable full communication from the clinicians to the patient and family and vice versa, and that this situation persists. Although ████████ statement indicates that the Trust “will work towards” informed consent being undertaken as an outpatient, the current absence of a system to facilitate informed consent being taken and to ensure it is obtained prior to the patient’s admission for the procedure in question, is of concern in relation to the prevention of future deaths. ”

    Source location

    Marian Hoskins · 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

    Absence of a system ensuring informed consent before procedure admission

    Wider context from the report

    “From the evidence I heard it was apparent that the insufficient discussion with Mrs Hoskins about the investigatory options resulted, in large part at least, from the absence of a clear system and process designed to ensure that full and informed consent is obtained. In particular, the advice and decision making about the pressure wire testing was made (in principle at least) at about the time of her initial percutaneous stenting in October 2016 and without sufficient subsequent out-patient access to advice and discussion. Prior to the conclusion of the Inquest I received a statement dated 21 November 2018 from ████████, Director of Quality and Safety. ████████ stated that the Trust has started a “major quality improvement project” to improve the process of gaining informed consent and he set out details of steps which have already been taken and those planned. In paragraph 10 of the statement it is noted that informed consent is a process that is undertaken over time and that the Trust’s current process does not include informed consent being obtained prior to the patient being admitted for a specific procedure. I am concerned that the insufficiency of the process in the Deceased’s case resulted largely from the absence /insufficiency of outpatient contact to enable full communication from the clinicians to the patient and family and vice versa, and that this situation persists. Although ████████ statement indicates that the Trust “will work towards” informed consent being undertaken as an outpatient, the current absence of a system to facilitate informed consent being taken and to ensure it is obtained prior to the patient’s admission for the procedure in question, is of concern in relation to the prevention of future deaths. ”

    Source location

    Marian Hoskins · Prevention of Future Deaths report
    Page 3 · 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

    Review Trust consent processes and pathways for elective procedures through a task and finish group.

    Verbatim wording from the response

    “From a Trust perspective work on this matter has been led by the Surgery Network board who established a task and finish group to review consent processes and pathways for elective procedures across the Trust.”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 23 May 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

    Develop a new Trust policy governing informed consent and supported decision-making for elective surgical procedures.

    Verbatim wording from the response

    “From a Trust perspective work on this matter has been led by the Surgery Network board who established a task and finish group to review consent processes and pathways for elective procedures across the Trust.”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 23 May 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

    Consult on the draft informed-consent policy before submitting it for Trust Policies Committee approval.

    Verbatim wording from the response

    “The outcome of this group has been a proposed new Trust policy ‘Informed Consent and Supported Decision Making for Elective Surgical Procedures’. The draft policy is currently out for consultation and we anticipate this will be taken for approval at the Trust Policies Committee within the next 2-3 months.”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 23 May 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

    Submit the informed-consent policy for Trust Policies Committee approval within the anticipated two-to-three-month period.

    Verbatim wording from the response

    “The outcome of this group has been a proposed new Trust policy ‘Informed Consent and Supported Decision Making for Elective Surgical Procedures’. The draft policy is currently out for consultation and we anticipate this will be taken for approval at the Trust Policies Committee within the next 2-3 months.”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 23 May 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

    Introduce and rigorously implement the revised consent process, including extended outpatient clinic times, consent documentation and revised job plans.

    Verbatim wording from the response

    “We have already discussed the implications of proposed changes to the consent policy at St Bartholomew’s Hospital (extended outpatient clinic times, consent documentation, revised Job Plans etc.). We realise how profound a change the shift in Consent process and policy will be, and are determined to introduce at pace and ensure its rigorous implementation.”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 23 May 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 consent-process performance through the Trust’s internal audit, quality and safety meetings, hospital boards and surgical governance structures after policy approval.

    Verbatim wording from the response

    “Following approval of this policy there will be on-going audit of performance, via the trust internal audit schedule, Quality and Safety meetings, hospital boards and via the surgical networks and the surgery board. Training and resource will be given where there are areas for improvement”

    Source location

    2019-0005-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 23 May 2019

    Open published response
  4. South London

    AI-generated summary

    Julia Jane MacPherson · 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

    Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

    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 formally review mental capacity to consent to treatment

    Wider context from the report

    “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

    Source location

    Julia Jane MacPherson · 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

    Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.

    Verbatim wording from the response

    “The Trust has developed a Multidisciplinary Team (MDT) meeting template following a quality improvement project to enable every member of the MDT to contribute to the review. There is a section for families, carers and significant people in a service user’s life in which any concerns raised are documented to ensure these are discussed in the meeting and agreed actions to address these outlined.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 1 · response
    Published 19 January 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

    Continue auditing MDT template use, capacity assessments, and responses to family concerns.

    Verbatim wording from the response

    “A recent audit of the use of the MDT template and capacity assessments have shown that it is being used and that views and concerns of families are being addressed. These audits will be carried out on a regular basis to give assurance to the trust.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 1 · response
    Published 19 January 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

    Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.

    Verbatim wording from the response

    “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 2 · response
    Published 19 January 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

    Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.

    Verbatim wording from the response

    “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 2 · response
    Published 19 January 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

    Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

    Verbatim wording from the response

    “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 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

    Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

    Verbatim wording from the response

    “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

    Source location

    2018-0298-Response-by-CQC
    Page 2 · response
    Published 19 January 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

    Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

    Verbatim wording from the response

    “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    Open published response
  5. Black Country

    AI-generated summary

    Mrs Lily Townsend · 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

    Mrs Lily Townsend fell at home, was admitted to hospital with a fractured neck of femur, and died during cemented hemiarthroplasty after her oxygen saturation and blood pressure fell rapidly. Concerns included inadequate recording of her medical history, failure to identify her as being at extremely high risk for major surgery, inadequate consent, and whether an un-cemented operation might have reduced the risks.

    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 consent discussions about major-surgery risks

    Wider context from the report

    “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension. 2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given. 3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement. 4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk. b) Consent process inadequate. ”

    Source location

    Mrs Lily Townsend · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. West Sussex

    AI-generated summary

    Leilani Chute · 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

    Leilani Chute was delivered by Caesarean section after an unsuccessful trial of instrumental delivery and was in a moribund condition, with terminal bradycardia and no other signs of life. The inquest concluded that she died shortly after birth from hypoxic brain injury and umbilical cord occlusion. The principal concerns were the use of an unendorsed practice of manually pushing back the cervix and inadequate disclosure of relevant risks when obtaining consent for instrumental delivery rather than proceeding directly to Caesarean section.

    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 provide balanced relevant facts for informed consent

    Wider context from the report

    “(2) That the manner in which consent was sought from women in labour when there was a choice to be made between attempted instrumental delivery and going straight to a CS did not appear to provide them with the relevant facts in order to come to an informed choice, but presented those facts that favoured the doctor’s preferred approach to management. ”

    Source location

    Leilani Chute · 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

    Review Trust and specialty guidance on consent for informed patient choice.

    Verbatim wording from the response

    “i. Policy and guidance”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Strengthen specialty guidance on instrumental delivery and caesarean section to reflect RCOG consent guidance and informed patient choice.

    Verbatim wording from the response

    “Work is underway to strengthen the Trust’s specialty guidance on instrumental delivery and caesarean section to fully reflect Royal College of Obstetrics and Gynaecology (RCOG) guidelines on consent in these specific circumstances and place appropriate emphasis on informed patient choice.”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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 obstetric and gynaecological medical staff to complete the introduced obstetric consent module every three years.

    Verbatim wording from the response

    “The service has introduced a more in depth online training module for obstetric staff alongside the existing Trust mandatory annual online e-learning on consent. The recently introduced EIDO Healthcare online learning contains a specific module on consent in obstetrics and all obstetric and gynaecological medical staff are now required to undertake this training every three years. The uptake of training will be monitored by the Division and a link to the training is shown below. http://www.beinformedplus.com/”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Monitor uptake of the obstetric consent training.

    Verbatim wording from the response

    “The service has introduced a more in depth online training module for obstetric staff alongside the existing Trust mandatory annual online e-learning on consent. The recently introduced EIDO Healthcare online learning contains a specific module on consent in obstetrics and all obstetric and gynaecological medical staff are now required to undertake this training every three years. The uptake of training will be monitored by the Division and a link to the training is shown below. http://www.beinformedplus.com/”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Use trainee feedback meetings and senior-staff appraisal to support reflection and learning about the consent process.

    Verbatim wording from the response

    “iii. Feedback and learning for the individuals involved in the consent process”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Existing Trust-wide consent guidance is considered clear and compliant with Montgomery, although specialty guidance is being strengthened.

    Verbatim wording from the response

    “In view of your concerns the Trust has reviewed both the overall Trust guidance and the relevant specialty guidance on consent. The existing overall Trust guidance gives clear guidance on informed patient choice and fully reflects the implications of the recent Montgomery judgment.”

    Source location

    2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    Open published response
  7. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 complete consent detailing chest drain complications

    Wider context from the report

    “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

    Source location

    Mr Critall · Prevention of Future Deaths report
    Page 3 · 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

    Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.

    Verbatim wording from the response

    “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    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 radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.

    Verbatim wording from the response

    “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    Open published response
  8. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Robert James Stuart and Darren Llewellyn Hughes · 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

    Robert James Stuart and Darren Llewellyn Hughes developed meningoencephalitis after receiving kidney transplants from the same donor and died on 17 and 19 December 2013 respectively. The infection was caused by a Halicephalobus nematode in the transplanted kidneys. Concerns included incomplete transmission of donor information, inadequate use of the EOS system and the need for a more multidisciplinary organ-acceptance process.

    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

    Use of an inadequate standard consent form for transplant operations

    Wider context from the report

    “(3) The Coroner heard that a standard consent form is used for all operations, and heard evidence that this has proved unsatisfactory for transplant operations where issues have to be covered that are not catered for by the standard form ”

    Source location

    Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Surrey

    AI-generated summary

    Marjory Rosina ELLERY · 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

    Marjory Rosina Ellery was taken to Frimley Park Hospital with chest pains and was administered medication to which she was known to be allergic. She developed anaphylactic shock and died on 16 January 2014; concerns related to administering medication despite a known allergy and obtaining informed consent in those circumstances.

    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 informed consent for administering medication to which a patient has a known allergy

    Wider context from the report

    “2. Action is required to ensure that consent obtained from a patient as to the administration of medication to which there is a known allergy is informed consent. ”

    Source location

    Marjory Rosina ELLERY · 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

    Require medical teams to discuss administration of allergy-causing medication with patients or applicable relatives, obtain consent, and document it.

    Verbatim wording from the response

    “A discussion with the patient must be undertaken by the medical team and consent gained from the patient (if able) or discussed with a relative where applicable and documented in the medical notes and signed by the patient.”

    Source location

    2014-0519-Response-by-Frimley-Health-NHS-Trust
    Page 1 · response
    Published 26 November 2014

    Open published response
  10. Manchester South

    AI-generated summary

    Mary Fenton · 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

    Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.

    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 document unavailable consent or self-consenting rationale

    Wider context from the report

    “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital) ”

    Source location

    Mary Fenton · 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 obtain consent to treatment

    Wider context from the report

    “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital) ”

    Source location

    Mary Fenton · 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

    Roll out refresher training on mental-capacity, consent and communication policies.

    Verbatim wording from the response

    “As to the actions of the particular staff involved in the care of Mrs Fenton, and with particular reference to the assessment and documentation of mental capacity, consent and communication, we have reminded the clinicians of the relevant policies and advised them that we will be rolling out refresher training. All Cardiology staff have also been informed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU / Ward 31 without the consent of a Consultant Cardiologist / the on-call Cardiologist for pacing out of hours.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 5 · response
    Published 13 October 2014

    Open published response
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Data last updated 7 September 2026