Recurring concern

Failure to provide treating clinicians with relevant patient history and baseline information

First to latest report 19 Jan 2018 — 30 Jul 2025

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
15

What this concern includes

Includes failures to gather, provide, display or make available relevant patient history, baseline status and underlying health information to the treating clinicians responsible for assessment or treatment, including information available through records, alerts, medic-alert information or clinical handover.

What is not included
  • Excludes generic clinical-record, communication or handover deficiencies where relevant patient history or baseline information is not the material unsafe object.
  • Excludes failures to act on complete and accessible patient history or baseline information when the information-provision process itself was reliable.
  • Excludes condition-specific information systems or pathways, such as allergy, VTE, mental-health or oxygen-information systems, when that named concern is the more specific supported boundary.
  • Excludes information provided solely for administrative, legal or non-clinical purposes.

Reports and published responses 7 reports

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

  1. North Yorkshire and York

    AI-generated summary

    Joanne Louise STONES · 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

    Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.

    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 identify and make visible patients’ relevant diagnoses to the treating team

    Wider context from the report

    “(1) The ambulance service pre-alerted the hospital regarding Joanne’s serious condition but this did not result in her being prioritised and placed in Resus on arrival. Joanne was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible ‘red flags’ on Joanne’s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions. ”

    Source location

    Joanne Louise STONES · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind staff through the learning-on-a-postcard system to check electronic alerts and patients’ medic-alert bracelets.

    Verbatim wording from the response

    “The action that we will take to resolve these issues going forward is two-fold: we have reminded all staff of the importance of checking alerts on CPD and medic-alert bracelets on the patient by means of our “learning on a postcard” system. In addition, we are in the process of implementing a new electronic patient record system (known as Nervecentre) and we will ensure that the alerts on this system have improved visibility, in order to maximise the chance of clinicians seeing and acting on these alerts.”

    Source location

    Response from York and Scarborough Teaching Hospitals
    Page 2 · response
    Published 31 July 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the Nervecentre electronic patient record with improved visibility of clinical alerts.

    Verbatim wording from the response

    “The action that we will take to resolve these issues going forward is two-fold: we have reminded all staff of the importance of checking alerts on CPD and medic-alert bracelets on the patient by means of our “learning on a postcard” system. In addition, we are in the process of implementing a new electronic patient record system (known as Nervecentre) and we will ensure that the alerts on this system have improved visibility, in order to maximise the chance of clinicians seeing and acting on these alerts.”

    Source location

    Response from York and Scarborough Teaching Hospitals
    Page 2 · response
    Published 31 July 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include clinical alerts in the Emergency Department’s two-day departmental induction.

    Verbatim wording from the response

    “In addition, the subject of alerts is discussed in detail in the ED two-day departmental induction.”

    Source location

    Response from York and Scarborough Teaching Hospitals
    Page 2 · response
    Published 31 July 2025

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    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 hospital computer alert for antiphospholipid syndrome and steroid treatment was present and visible when the patient attended, but was not noted.

    Verbatim wording from the response

    “The only time that Ms Stones’ medical history was referenced in the clinical notes was in the nursing notes when she was referred to the Emergency Assessment Unit for further investigation of her chest (which was subsequently identified as abdominal) pain. The assumption therefore is that the bracelet wasn’t seen, or if it was, its importance wasn’t recognised. The CPD system is designed to remove the computer APD/steroid treatment alert if a patient dies (because of the need to remove the individual from the locality steroid register) and so can’t be seen on CPD at present. However, we are confident that the alert was present and visible when Ms Stones presented at the time, but unfortunately not noted by the treating clinicians. The alerts on CPD are not as obvious as they could be (they are displayed on a tab at the top of the screen in a light blue colour).”

    Source location

    Response from York and Scarborough Teaching Hospitals
    Page 2 · response
    Published 31 July 2025

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Ian Jacka · 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

    Ian Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex patients.

    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

    Unavailability of neurological status information to surgical and anaesthetic teams

    Wider context from the report

    “(5) The surgical and anaesthetic team had no reason to suspect a secondary brain injury. The team had no information on Ian’s neurological status. Ian is likely to have suffered a hypoxic brain injury during the critical incident of 5th June. This will have undermined his resilience and ability to physically withstand the rigors of spinal surgery and airway exchange. ”

    Source location

    Ian Jacka · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review current intensive care-to-theatre transfer and handover practice.

    Verbatim wording from the response

    “A review of the current practice for reviewing and handing over patients who require transfer from the Intensive Care Unit to the operating theatre has been undertaken. Currently patients are reviewed by the surgical and anaesthetic teams pre-operatively and information is collected and documented by the anaesthetic team using a structured Pre-operative Anaesthetic Assessment chart in keeping with standard procedures across the Trust. The anaesthetic team assess the patient and examine/record relevant information relating to the patient’s history, airway assessment, cardiorespiratory system, and any diagnostic tests and results. The pre-operative assessment is undertaken to formulate a clear anaesthetic plan, but also provides an opportunity to seek additional information, optimise the patient if required, and consider if the surgery is safe to proceed.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 3 · response
    Published 18 December 2023

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create a pre-operative handover checklist for complex intensive care patients, covering airway, allergies, medications, clotting, blood products and other relevant care information.

    Verbatim wording from the response

    “decision makers, as well as improving the quality of information that is received. The Trust is committed to ensuring that the quality of handovers is as robust as possible given the well evidenced risks, and therefore the following actions have been agreed.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 4 · response
    Published 18 December 2023

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    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

    No further pre-operative investigations were considered necessary because neurological assessment showed no change after intubation.

    Verbatim wording from the response

    “The decision to progress to surgical fixation of Mr Jacka’s thoracic spinal injuries was made by the surgical team in consultation with the Intensive Care team and in the knowledge that he had been intubated for respiratory failure early on the 5th June. He had an appropriate clinical neurological assessment during the daytime on the 5th June and was demonstrated to be unchanged following intubation. No other investigations were deemed necessary pre-operatively by the surgical or Intensive Care teams.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 3 · response
    Published 18 December 2023

    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 pre-operative assessment, intensive-care access and theatre briefing arrangements address relevant information-sharing needs, alongside a narrower new checklist.

    Verbatim wording from the response

    “A review of the current practice for reviewing and handing over patients who require transfer from the Intensive Care Unit to the operating theatre has been undertaken. Currently patients are reviewed by the surgical and anaesthetic teams pre-operatively and information is collected and documented by the anaesthetic team using a structured Pre-operative Anaesthetic Assessment chart in keeping with standard procedures across the Trust. The anaesthetic team assess the patient and examine/record relevant information relating to the patient’s history, airway assessment, cardiorespiratory system, and any diagnostic tests and results. The pre-operative assessment is undertaken to formulate a clear anaesthetic plan, but also provides an opportunity to seek additional information, optimise the patient if required, and consider if the surgery is safe to proceed.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 3 · response
    Published 18 December 2023

    Open published response

  3. North East Kent

    AI-generated summary

    KEITH RUPERT DIMOND · 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

    Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.

    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 communicate the iliac artery aneurysm diagnosis to treating clinicians

    Wider context from the report

    “(1) Treating Clinicians stated they were not aware of the diagnosis of Iliac Artery Aneurysm previously made at the Trust in August 2019 even though this was set out in the medical records and made at the same time as the diagnosis of Aortic Abdominal Aneurysm that was known. A abdominal surgery and anticoagulation were undertaken without consideration of this information. ”

    Source location

    KEITH RUPERT DIMOND · 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

    Implement and expand Sunrise digital clinical documentation, results access and patient-observation recording across the organisation.

    Verbatim wording from the response

    “The Trust has become more digitally mature as an organisation; there have been several developments which have significantly improved the clarity and accessibility of our medical records. In October 2020, we launched Sunrise which provides ordering and viewing of test results. This was followed by the introduction of moving the documentation of the A&E clinical notes onto this system. Following on from this in June 2021 Sunrise was launched onto the wards for all clinical documentation and now includes patient clinical observations (blood pressure, heart rate etc). These significant improvements enable the clinical teams to access digitally the clinical notes and important results in one place which are accessible from anywhere within the organisation.”

    Source location

    Response from East Kent Hospitals University
    Page 1 · response
    Published 28 October 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue improving Sunrise to support record-keeping quality and patient safety.

    Verbatim wording from the response

    “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.”

    Source location

    Response from East Kent Hospitals University
    Page 1 · response
    Published 28 October 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revisit clinician training so staff can access all parts of the clinical record.

    Verbatim wording from the response

    “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.”

    Source location

    Response from East Kent Hospitals University
    Page 1 · response
    Published 28 October 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure surgical clinicians understand their medical-record access responsibilities and include this requirement in new-staff induction.

    Verbatim wording from the response

    “In addition, our surgical site leads are ensuring all the clinicians in the department including seniors, understand their responsibility regarding accessing of medical records in line with GMC good medical practice and this will also be part of our induction for new staff. This case will be discussed at departmental morbidity and mortality meetings Trust wide for additional learning and the individual clinicians involved to include their personal reflection and learning within their annual appraisal.”

    Source location

    Response from East Kent Hospitals University
    Page 2 · response
    Published 28 October 2022

    Open published response

  4. South Wales Central

    AI-generated summary

    Manon Edie Jones · 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

    Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.

    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

    Unavailability of community care records to clinicians on admission

    Wider context from the report

    “(1) The clinicians assessing Manon on admission to Ty Llidiard did not have available to them the records of her care made in the community by the Crisis team, the Community Intensive Treatment team or the University Hospital of Wales ”

    Source location

    Manon Edie Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Joseph Hargreaves · 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

    Joseph Hargreaves had an unwitnessed fall at his care home and was admitted to hospital with sepsis due to aspiration pneumonia associated with poor swallowing. He initially appeared to improve but deteriorated rapidly and died on 17 April 2020. The report identified concerns about reduced information-sharing with treating clinicians regarding the events before admission and his baseline and underlying health issues, particularly when family members could not visit during lockdown.

    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

    Reduced provision of information about events leading up to admission and baseline and underlying health issues to treating clinicians

    Wider context from the report

    “The provision of information, about the events leading up to his admission; his baseline and underlying health issues, to treating clinicians was reduced. In his case it did not impact the outcome however it was clear from the evidence that it could in other circumstances cause significant challenges in delivering effective treatment quickly to vulnerable patients. ”

    Source location

    Joseph Hargreaves · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Derby and Derbyshire

    AI-generated summary

    Mrs Christine Forbes · 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 Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.

    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 ensure clinicians know patients' full medical history before treating and prescribing

    Wider context from the report

    “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known. ”

    Source location

    Mrs Christine Forbes · 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

    Enable all Derby and Derbyshire general practices to use GP2GP electronic record transfer.

    Verbatim wording from the response

    “All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP practice.”

    Source location

    2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
    Page 1 · response
    Published 19 November 2020

    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

    Offer Ashbourne Medical Practice additional GP2GP and electronic record transfer training.

    Verbatim wording from the response

    “• Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice”

    Source location

    2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
    Page 3 · response
    Published 19 November 2020

    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

    Offer Ashbourne Medical Practice additional note summarisation training.

    Verbatim wording from the response

    “• Offer additional training Note Summarisation to Ashbourne Medical Practice”

    Source location

    2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
    Page 3 · response
    Published 19 November 2020

    Open published response

  7. Manchester West

    AI-generated summary

    William Myers · 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

    William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate 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 circulate important clinical risk information to treating clinicians

    Wider context from the report

    “(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community. ”

    Source location

    William Myers · 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

    Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.

    Verbatim wording from the response

    “The trust is reviewing all care-planning procedures in the light of the lessons learned from this case to ensure that there is continuity of care and a consistent management plan with particular emphasis on high-risk individuals. Discharge procedures have also been reviewed and high-risk patients should not be discharged without a completed formal discharge care plan and risk assessment with consultant oversight. The discharge care plans will include consideration of the risk of disengagement and non-compliance and the response to these.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 2 · response
    Published 14 March 2018

    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

    Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.

    Verbatim wording from the response

    “Patients with a significant forensic history are now being identified on the newly developed special notes system within AMIGOS the current Electronic Patient Record used in our Manchester services so that individuals presenting will have care plans and discharge plans, which are informed by these risks.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 3 · response
    Published 14 March 2018

    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 the approved PARIS electronic clinical record system across Manchester services.

    Verbatim wording from the response

    “GMMH has developed a business case to introduce the PARIS electronic clinical record system bring our Manchester services in line with the wider Trust. This has now been approved by the GMMH Trust Board and will be introduced over the next 12-15 months. This will further enhance accessibility of these assessments to the treating teams.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 3 · response
    Published 14 March 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026