Recurring concern

Failure to provide patient-centred care and decisions

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First reported 12 Mar 2014•Latest report 14 Jan 2026

Definition

What this concern includes

Includes failures in patient-centred care delivery or patient-care decision-making where staff or services lose sight of the individual patient and fail to account for their needs, circumstances, preferences or relevant safety information.

Not included

  • Excludes failures belonging to a separately named clinical, safeguarding, statutory or operational system where that system provides the more specific supported boundary.
  • Excludes generic poor communication, documentation, staffing or governance deficiencies unless they directly result in non-patient-centred care or decisions.
  • Excludes dissatisfaction or disagreement with a clinical decision where the decision was individualised, adequately informed and appropriately involved the patient.
  • Excludes failures concerning family or carer involvement where patient-centred care is not the shared unsafe condition.
Reports
12

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
16

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3
Kent and Medway Mental Health NHS Trust2
NHS England2
Tees, Esk and Wear Valleys NHS Foundation Trust2
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
HM Prison and Probation Service1
HM Prison Service1
Isle of Wight NHS Trust1
NHS Hampshire and Isle of Wight Integrated Care Board1
NHS Humber and North Yorkshire Integrated Care Board1
NHS Surrey and Sussex Integrated Care Board1
North Tees and Hartlepool NHS Foundation Trust1
Recipient name withheld1
Richmond Companions International (RCI)1

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. Isle of Wight

    AI-generated summary

    Cuthbert Anthony Stanley Hingert · 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

    Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.

    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 safe clinical decision-making when prescribing hypnotics to confused patients

    Wider context from the report

    “6. A decision was made to treat Mr Hingert, who was already confused, with the hypnotic Zopiclone, which may not have been a sound clinical decision. ”

    Source location

    Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Teesside

    AI-generated summary

    Andrew Ronald Hall · 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

    Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

    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 by mental health and general nursing staff to take account of system 1 entries

    Wider context from the report

    “6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████ ”

    Source location

    Andrew Ronald Hall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026