Recurring concern

Failure to reliably notify primary care of changes affecting patient care

First to latest report 9 Sep 2013 — 15 Oct 2025

Reports that mention this concern
21
Times this concern has been raised
22
Stated actions linked to this concern
18

What this concern includes

Includes failures of dedicated notification arrangements to a patient's GP or outgoing primary-care practice about material changes affecting responsibility, access, admission or continuity of the patient's care, including care transfers, hospital admissions and non-engagement with referred services.

What is not included
  • Excludes generic inter-agency communication or information-sharing failures where the notification is not specifically to primary care about a material change affecting patient care.
  • Excludes clinical information, medication details or discharge information unless the reported unsafe condition is failure to notify primary care of the relevant care-status change.
  • Excludes failures to notify patients, families, coroners, emergency services or other recipients where primary care is not the relevant notification recipient.
  • Excludes routine administrative updates that do not affect responsibility, access, admission or continuity of patient care.

Reports and published responses 21 reports

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

  1. City of London

    AI-generated summary

    Tony Montana Duncan · 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

    Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

    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 alert relevant services, the GP, or family about a high-risk patient’s departure

    Wider context from the report

    “3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation. ”

    Source location

    Tony Montana Duncan · Prevention of Future Deaths report
    Page 4 · 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

    Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.

    Verbatim wording from the response

    “Ideally, the PLN would have sought Mr Duncan’s consent to contact a named person/carer, ideally his mother with whom he lived, but did not do this; the AAR has made a recommendation to address this omission by embedding ‘carer contact’ in the Liaison Psychiatry departmental handover board; this must be done and documented before patients can be discharged. The Trust is accredited under the Triangle of Care initiative led by the Carers Trust and endorsed by NHS England, which seeks to implement six key standards required to achieve better collaboration and partnership with carers, including identification of carers at first contact; the implementation of this in the ED can be difficult for reasons outlined in the AAR, and this extra flag is intended to provide further operational support for future patient cases.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 5 · response
    Published 20 October 2025

    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

    Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.

    Verbatim wording from the response

    “The AAR did note that adult patients with mental capacity to make the relevant decision may well decline or refuse a request to contact their family, but in this case there is no documentation that this discussion took place. Family members are often able to provide useful collateral information which can assist in care planning, even if the patient does not permit the clinician to share information about them. However, if a patient refuses to allow contact, it may not be possible to make this contact. This should be noted in the electronic record.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 5 · response
    Published 20 October 2025

    Open published response

  2. Essex

    AI-generated summary

    Julie Sheila Beasley · 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

    Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her 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

    Failure to communicate discharge actions to the GP

    Wider context from the report

    “(1) Mrs Beasley was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs Beasley was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP. ”

    Source location

    Julie Sheila Beasley · 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

    Send patient contact details and highlighted actions to GPs through administrative support.

    Verbatim wording from the response

    “By way of evidence provided to the Court, the team have clear processes for GPs to be emailed following any patient contact. Clinical staff are supported by the Team administrative personnel who are tasked with sending assessment details to GP’s, which includes highlighted actions.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 4 June 2025

    Open published response

  3. Oxfordshire

    AI-generated summary

    Caroline Diane Harris · 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

    Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.

    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 inform the GP of declined attendance for medication

    Wider context from the report

    “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’. MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT. Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act. My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. You should consider a review of how such information is assessed and shared between the respective agencies. ”

    Source location

    Caroline Diane Harris · 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 qualifying mental-health reports with GPs, explain the reasons, and request follow-up and identification of social-care needs.

    Verbatim wording from the response

    “10. The guidance issued to the Social and Health Care Team in August 2023, states that a report is shared with the person’s GP in the following circumstances.”

    Source location

    Response from Oxfordshire County Council
    Page 6 · response
    Published 17 July 2026

    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

    Escalate urgent concerns by contacting GPs immediately or referring cases to the Professional Support Team for evaluation and decision.

    Verbatim wording from the response

    “11. Where the situation appears to be urgent the team will either:”

    Source location

    Response from Oxfordshire County Council
    Page 6 · response
    Published 17 July 2026

    Open published response

  4. Inner North London

    AI-generated summary

    Mohammed Zeeshan Akram (Zee) · 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

    Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

    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 update prescribing GPs about medication non-adherence and stockpiling risks

    Wider context from the report

    “I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed. I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling. ”

    Source location

    Mohammed Zeeshan Akram (Zee) · 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

    Existing medication-review procedures and subsequent GP notification were considered sufficient; no additional GP communication was expected before the review.

    Verbatim wording from the response

    “This medication review by the prescribing clinician will automatically lead to the GP being notified when there are any changes to the client’s prescription or treatment plan, including whether the client has stopped taking the medication and any steps the service is taking to provide additional support. The expected standard is the GP would receive this correspondence via email within 48 hours of the medical review. In cases where a rapid medical review is arranged, the service will usually wait until the review before updating the GP, to ensure the GP is provided with the most up to date treatment plan.”

    Source location

    Response from Barnet Enfield and Haringey Mental Health NHS Trust
    Page 2 · response
    Published 29 November 2023

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Leva Amra ADRIS · 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

    Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.

    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 inform referring GPs when referrals to secondary services are rejected

    Wider context from the report

    “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. ”

    Source location

    Leva Amra ADRIS · 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

    Establish effective working relationships and clarify referral processes between mental health services and general practice.

    Verbatim wording from the response

    “Firstly, may I apologise for the delay in our response and assure you that our organisation takes the findings seriously. We appreciate the thoroughness of your investigation and the comprehensive matters of concern outlined in your report. We are committed to working with partner to address these concerns and we note the response from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 15th December 2023. In particular, we will ensure that BSMHFT and General Practice have effective working relationships with clarity of referral processes between the two providers particularly with regards to the transformed Community Mental Health and Wellbeing Service and the associated referral form and processes.”

    Source location

    Response from Birmingham and Solihull
    Page 1 · response
    Published 13 November 2023

    Open published response

  6. Cumbria

    AI-generated summary

    Brenda SHIELDS · 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

    Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.

    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

    Delays in sending discharge notifications to GPs

    Wider context from the report

    “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made. ”

    Source location

    Brenda SHIELDS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner South London

    AI-generated summary

    Mr Locksley Burton · 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 Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

    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 reductions in clinic attendance and dressing changes to the GP

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”

    Source location

    Mr Locksley Burton · 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

    Improve communication from secondary care to primary care with colleagues across specialties.

    Verbatim wording from the response

    “The circumstances raise issues with communication from secondary care to primary care, an issue that the RCGP is working to improve with our colleagues across all specialties. In addition, the RCGP continues to work with NHS England and NHS Improvement to improve the communication links between primary and secondary care.”

    Source location

    Response from Royal College of General Practitioners
    Page 1 · response
    Published 29 September 2022

    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

    Work with NHS England and NHS Improvement to improve communication links between primary and secondary care.

    Verbatim wording from the response

    “The circumstances raise issues with communication from secondary care to primary care, an issue that the RCGP is working to improve with our colleagues across all specialties. In addition, the RCGP continues to work with NHS England and NHS Improvement to improve the communication links between primary and secondary care.”

    Source location

    Response from Royal College of General Practitioners
    Page 1 · response
    Published 29 September 2022

    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

    GP communication was unnecessary because there was no significant change in management, dressing frequency or foot condition.

    Verbatim wording from the response

    “The GP did not know of the reduction in clinic attendance or reduction in changes of dressings and assumed others were inspecting the wound and prescribed antibiotics without an examination being done.”

    Source location

    Response from Kings College Hospital
    Page 2 · response
    Published 29 September 2022

    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 Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.

    Verbatim wording from the response

    “As the Coroner has correctly concluded, the pandemic was the reason that the DFC reduced its attendance. The GP was made aware of this during his attendances at the Home during the relevant period. We do note however that it was a period of unprecedented uncertainty and many services, the DFC included, were running a reduced service and attempting to adapt to the changing status of contact with individuals requiring care during this period.”

    Source location

    Response from The Kind Care Company
    Page 2 · response
    Published 29 September 2022

    Open published response

  8. Sefton St Helens & Knowsley

    AI-generated summary

    Joan RICHARDSON · 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

    Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

    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 inform appropriate clinical and social care services of pressure injuries

    Wider context from the report

    “(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”

    Source location

    Joan RICHARDSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Surrey

    AI-generated summary

    Hannah Bampfylde · 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

    Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to routinely notify GPs of non-attendance with HATS

    Wider context from the report

    “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services. Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work. No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement. Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this. The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place. HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service. The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator. The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place. - Appointments are not automatically re-booked when a person has failed to attend an appointment. - It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors). - GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Hannah Bampfylde · 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

    Provide weekly administrative support to identify all DNA cases.

    Verbatim wording from the response

    “The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.”

    Source location

    2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Notify GPs when patients are discharged from Horsham ATS because of repeated non-attendance or non-engagement.

    Verbatim wording from the response

    “The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.”

    Source location

    2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 5 May 2021

    Open published response

  10. Inner South London

    AI-generated summary

    Master Omarian Brooks · 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

    Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the 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 inform the GP of patient deterioration

    Wider context from the report

    “1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after, he would have been admitted to hospital with a real prospect of the infection being successfully treated. ”

    Source location

    Master Omarian Brooks · 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 a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.

    Verbatim wording from the response

    “4. The GPs have implemented a policy for circumstances where ‘rescue pack’ antibiotics are prescribed to patients with complex needs on a repeat basis. This policy includes an agreement which has to be made between the GPs and the parents. This agreement”

    Source location

    2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
    Page 1 · response
    Published 10 June 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

    Bring together professional colleges to develop standards promoting connectivity, proactive care, and communication for children with ongoing health needs.

    Verbatim wording from the response

    “• In 2018, the College brought together the Royal College of General Practitioners, Royal College of Nursing, Royal College of Physicians and Royal College of Psychiatrists to develop Facing the Future: Standards for children with ongoing health needs³ to ensure connectivity between services, with a focus on improving long term care and management so that care is planned and proactive - particularly with improving communication and education for both the child and family, and communication between professionals.”

    Source location

    2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
    Page 2 · response
    Published 10 June 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

    Publish a position on information sharing and consistent identifiers for children to support professionals’ access to information and care coordination.

    Verbatim wording from the response

    “• The College has a published position on information sharing and maintains that having a unique, consistent identifier for children will allow professionals interacting with children to share information easily and provide better care for their needs.⁴”

    Source location

    2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
    Page 2 · response
    Published 10 June 2020

    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