Recurring concern

Failure to acknowledge and act on family and carer safety concerns in patient care

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First reported 6 Sep 2013•Latest report 24 Jun 2026

Definition

What this concern includes

Includes failures within patient-care processes to receive, acknowledge, recognise, record, investigate, escalate or act on safety concerns raised by parents, families, carers or next of kin, including concerns about a child's condition or care and concerns raised during hospital or community care.

Not included

  • Excludes generic communication, information-sharing or documentation deficiencies where no family or carer safety concern about patient care is involved.
  • Excludes routine dissatisfaction or complaints without a material patient-safety concern.
  • Excludes concerns raised by employees, clinicians or other professionals when the unsafe condition is not the handling of a family or carer concern.
  • Excludes failures confined to informing families or carers about care when they did not themselves raise a safety concern.
  • Excludes complaints-handling failures in non-healthcare settings or care-setting-specific processes where an existing narrower concern provides the more faithful boundary.
Reports
19

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
32

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.

Care Quality Commission3
Department of Health and Social Care3
Essex Partnership University NHS Foundation Trust3
Health and Safety Executive2
NHS England2
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
East London NHS Foundation Trust1
European Care & Lifestyles (UK) Limited1
Greater Manchester Integrated Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
HCRG Care Coventry LLP1
Kent and Medway Mental Health NHS Trust1
NHS Birmingham and Solihull Integrated Care Board1
NHS Coventry and Warwickshire Integrated Care Board1

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. Inner North London

    AI-generated summary

    Riya HIRANI · 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

    Riya Hirani, aged nine, was transferred to Great Ormond Street Hospital after presenting in cardiac arrest, having previously been assessed and discharged from Northwick Park Hospital. The concerns were that the severity of her illness was not recognised, despite her mother's repeated concerns, and that she was not given intravenous antibiotics, admitted, or escalated for a second opinion. Riya died five days after the cardiac arrest; her recorded cause of death included hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest, invasive group A streptococcal infection and influenza B infection.

    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 escalate care in response to clearly expressed parental concerns about a deteriorating child

    Wider context from the report

    “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats. I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally. When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.) I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation. One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends. Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care. I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed. ”

    Source location

    Riya HIRANI · 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, ratify, disseminate and audit a paediatric examination SOP covering escalation, SBAR handovers, senior opinions and mandatory face-to-face review before discharge.

    Verbatim wording from the response

    “New standard operating procedure”

    Source location

    Response from London North West University Healthcare NHS Trust
    Page 1 · response
    Published 22 September 2023

    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

    Advise clinicians to seek senior review when caregivers remain concerned after clinical review.

    Verbatim wording from the response

    “As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review.”

    Source location

    Response from London North West University Healthcare NHS Trust
    Page 2 · response
    Published 22 September 2023

    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 the nationally approved Paediatric Early Warning System observation and escalation charts.

    Verbatim wording from the response

    “Nationally approved Paediatric Early Warning System”

    Source location

    Response from London North West University Healthcare NHS Trust
    Page 2 · response
    Published 22 September 2023

    Open published response

  2. Essex

    AI-generated summary

    Bency Joseph · 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

    Bency Joseph died instantly on 27 May 2022 from a traumatic head injury after falling headfirst from an upstairs window at home during a severe psychotic episode. The concerns included delays in prescribing and providing therapeutic medication, failure to act on the family’s attempts to escalate the issue, and shortcomings in the Trust’s investigation, including not involving the family or Senior Pharmacist.

    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 involve the deceased patient's family in the Trust investigation

    Wider context from the report

    “(2) The Trust investigation did not: a. Inform or involve the Trust Senior Pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation. b. Involve the Family of the deceased c. Lost an opportunity to understand concerns that the Family had been trying to access additional urgent medication prescribed on 26 May 2022 without success and had been telephoning the Trust to raise an alert. ”

    Source location

    Bency Joseph · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to action family concerns and escalations about urgent medication

    Wider context from the report

    “(1) Essex Partnership NHS Foundation Trust Mental Health Liaison Psychiatrist assessed Bency Joseph as suffering from a first episode psychosis when she attended hospital on 23rd May as an emergency and there was a delay in prescribing and administering therapeutic medication required for a first episode of psychosis with delusions. a. ████████ Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic. One dose of medication was administered and Bency Joseph was discharged under the care of the Home Treatment Team. b. On 26 May the Home Treatment Team consultant psychiatrist found that Bency Joseph did not have capacity, had deteriorated and prescribed urgent medication to be provided on the same day. The medication was not provided. c. It is unclear if the urgent prescription was received and processed. d. The Family’s concerns and attempts to escalate the failure to provide the medication were not actioned by the Trust and the death occurred in the early morning of 27 May as the Family were making arrangements to take Bency Joseph back to accident and emergency due to the omission to provide medication and further deterioration. ”

    Source location

    Bency Joseph · 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

    Share learning about involving pharmacy expertise in clinical review investigations with the Clinical Review Group chair.

    Verbatim wording from the response

    “Following notification of Mrs Joseph’s death, the Trust’s Clinical Review Group reviewed details of the incident on 14 June 2022 and requested that a Clinical Review be completed. The Group directed that the scope of the review should be from Mrs Joseph’s first contact with the Trust until her death and that any questions from the family should also be answered. At that point in time, it was not evident that involvement from the Trust’s Director of Pharmacy would be required, however the Trust acknowledges that when the report was reviewed by the Clinical Review Group, the Group should have picked up on this point and requested input prior to final approval of the report. This learning has been shared with the Chair of the Clinical Review Group.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 17 May 2023

    Open published response

  3. Berkshire

    AI-generated summary

    Frederick Robert Peter King · 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

    Frederick Robert Peter King was a resident at Birchwood Care Home and died in hospital on 9 September 2021 from an acute kidney injury caused by dehydration, with frailty and vascular dementia contributing to his death. The concerns included inadequate fluid provision, incomplete care records, and the absence of a care-home manager on the ground in the three days before his death.

    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 and convey family health concerns

    Wider context from the report

    “(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed. ”

    Source location

    Frederick Robert Peter King · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The provider has taken sufficient action to mitigate risks and prevent future deaths.

    Verbatim wording from the response

    “We sent an urgent letter to the provider West Berkshire Council to confirm CQC had received the regulation 28 report and asked them to set out in writing evidence of the actions they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. We received a detailed response from the provider. We are satisfied the provider has taken sufficient action according to section 6 of the regulation 28 report to mitigate risks to people and prevent future deaths.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 November 2022

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Azra Parveen HUSSAIN · 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

    Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

    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 significant family concerns and patient accounts

    Wider context from the report

    “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”

    Source location

    Azra Parveen HUSSAIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Coventry

    AI-generated summary

    Vanessa Ferkova and Sylvia Daniel · 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

    Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging 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

    Failure to act on deterioration or requests for earlier prompt review raised through the flagging process

    Wider context from the report

    “4. My final specific concern relates to the process whereby patients/families are asked to let the reception team know if the patient is deteriorating, or if they are concerned that earlier prompt review is required. I heard evidence that such concerns were raised but no action was taken. This seemingly runs counter to Virgin Care’s own ‘flagging’ system. ”

    Source location

    Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. London Inner (South)

    AI-generated summary

    John William Sloan · 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 William Sloan died by suicide on 16 August 2017 after hanging himself while alone at home. He had been receiving mental health care for anxiety, depression, sleeplessness and suicidal ideation. The principal concerns were that he was not asked about suicidal thoughts or plans at his last face-to-face contact, and that information from his daughter about his distress was not recorded or acted upon.

    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 concerns raised by family members

    Wider context from the report

    “(2) With regard to the contact with the Care co-ordinator on the 11/8/17 the failure to record the concerns of Mr Sloan’s daughter was a fundamental omission which also represented a missed opportunity to put in place supportive measures which may have prevented the death. ”

    Source location

    John William Sloan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Janet 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

    Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

    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 respond to or act on family concerns

    Wider context from the report

    “7. When Ms Williams’ family attempted to raise concerns with her care co-ordinator, at times their calls were not returned and at other times their concerns were simply not acted upon. She had recently been diagnosed with a very serious mental health condition, but she was not monitored with sufficient care or in some instances at all, and she was therefore not assessed or treated appropriately. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. East London

    AI-generated summary

    EMMA LOUISE BRAY · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to escalate family reports of changes in presentation for multidisciplinary review

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure AABIT staff are competent in risk assessment and escalation of risk.

    Verbatim wording from the response

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

    Source location

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

    Open published response

  9. Sunderland

    AI-generated summary

    Peter Pattinson · Prevention of Future Deaths report

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

    Report summary

    Peter Pattinson, who had complex medical needs, was readmitted to hospital after falling from his bed at Cedar Court Care Centre and died on 19 March 2013. Concerns included family requests for raised bed rails not being acted on or documented or subject to risk assessment, delayed repair of the bed rails, and missing or non-sequentially paginated daily statements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act on family concerns and requests about bed rails

    Wider context from the report

    “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

    Source location

    Peter Pattinson · 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 risk assess family concerns and bed-rail requests

    Wider context from the report

    “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

    Source location

    Peter Pattinson · 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 document family concerns and bed-rail requests

    Wider context from the report

    “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

    Source location

    Peter Pattinson · 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

    Carry out bed-rail risk assessments within 24 hours of admission and review them monthly or when residents’ needs change.

    Verbatim wording from the response

    “a. bed rail risk assessments are carried out within 24 hours of admission and are then reviewed monthly or when needs change. Any changes will be discussed with the service user or a family member; and”

    Source location

    2013-0250-Response-by-European-Care-Group
    Page 1 · response
    Published 6 September 2013

    Open published response
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Data last updated 7 September 2026