Recurring concern

Unreliable communication of patient-care information between clinical staff

First to latest report 21 Aug 2013 — 27 Feb 2026

Reports that mention this concern
124
Times this concern has been raised
133
Stated actions linked to this concern
193

What this concern includes

Includes failures to communicate relevant patient care, treatment or risk information between clinical staff responsible for the same patient's care.

What is not included
  • Formal handover processes where handover itself is the more specific unsafe control
  • Communication between separate organisations or agencies governed by a named information-sharing process
  • Documentation failures where relevant information was otherwise reliably communicated
  • Failure to act after information was reliably communicated

Reports and published responses 124 reports

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

  1. Nottinghamshire

    AI-generated summary

    Doreen Wood · 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

    Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

    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 relevant clinical information is systematically passed to the GP for INR dosing decisions

    Wider context from the report

    “(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”

    Source location

    Doreen Wood · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    James Paul COLTON · 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

    James Paul COLTON was a serving prisoner who became critically unwell on 29 August 2013 after a period of deteriorating health and died two days later in hospital. Concerns included failure to revisit his diagnosis or escalate treatment, inadequate analgesia, poor continuity and communication of care, and an extremely heavy workload affecting healthcare provision.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate communication between healthcare nurses and doctors

    Wider context from the report

    “(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment. ”

    Source location

    James Paul COLTON · 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

    Minute daily multidisciplinary lunchtime meetings, allocate actions, and record them in patient records.

    Verbatim wording from the response

    “Additionally, the daily lunchtime meeting at HMP Long Lartin is now properly minuted with actions being allocated and recorded in patient records. This meeting is attended by a range of staff and encourages greater discussion about the care of particular individuals. As a result of some of the issues raised in Mr Colton’s case, there have been changes to practices such as nurses undertaking pain scores. I am aware that individual nursing staff are more frequently recording pain scores in order to allow a judgment to be made as to whether a problem is persisting or becoming increasingly painful or resolving itself.”

    Source location

    2015-0021-Response-by-Worcestershire-Health-Care-NHS
    Page 1 · response
    Published 21 January 2015

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Philip Robinson · 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

    Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve 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 reliably record and communicate the Early Warning Score across healthcare staff

    Wider context from the report

    “The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital ”

    Source location

    Philip Robinson · 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

    Embed ward safety briefings and provide education to improve multidisciplinary communication of EWS.

    Verbatim wording from the response

    “• The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The safety brief at the end of the ward round involves the whole of the ward team including HCA’s to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit. Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 2015

    Open published response

  4. Inner South London

    AI-generated summary

    Archie Haxell · 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

    Archie Haxell was born by forceps delivery on 24 March 2013 and suffered a respiratory arrest about two hours after birth. He was transferred to St Thomas’ Hospital, where he died on 29 March 2013. The principal concerns were breakdowns in communication between healthcare professionals, failure to retain observation records, and failure to inform Archie’s parents about concerns regarding his breathing, contributing to delay in recognising his deteriorating condition.

    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 possible signs of respiratory distress between midwives

    Wider context from the report

    “(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally. During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives. Also, the piece of paper on which the observations were recorded was not retained. I am concerned that this should have been retained in the medical records. ”

    Source location

    Archie Haxell · 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

    Embed SBAR communication and escalation across the maternity service and monitor progress through quarterly Quality and Safety Committee updates.

    Verbatim wording from the response

    “SBAR Work is currently underway to embed the use of this communication tool (Situation, Background, Assessment, Recommendation) within the maternity service. This is a simple tool used by many NHS organisations to ensure that communication between healthcare professionals is clear and concise, and to support effective escalation of situations when necessary.”

    Source location

    2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 3 · response
    Published 5 March 2015

    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

    Participate in the national Sign Up to Safety campaign through a Trust-wide initiative to reduce avoidable harm from failure to identify and act on deteriorating patients.

    Verbatim wording from the response

    “This technique is already underway in the Children’s Division, the Maternity Service, and has been incorporated into a wider Trust initiative under the umbrella of the national Sign Up To Safety campaign and our pledge to reduce harm to the ‘deteriorating patient’. Progress will be monitored at the Trust’s Quality and Safety Committee where quarterly updates will be presented by the pledge leads. This committee is chaired by the Trust’s Deputy Medical Director for Quality and Safety.”

    Source location

    2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 3 · response
    Published 5 March 2015

    Open published response

  5. Northamptonshire

    AI-generated summary

    Jane Marie Clark and Isobel Griffin · 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

    Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature 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

    Failure to communicate and review relevant clinical information before risk decisions

    Wider context from the report

    “Re Jane Marie Clark 1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented. 2. She did not place any boundaries on the leave for example providing a time by which Jane was to return. 3. Risk assessment documentation generally was poor and appeared perfunctory. Re Isobel Griffin 1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th. 3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature. 4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family. 5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment. 6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances. 7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk. ”

    Source location

    Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. London (East)

    AI-generated summary

    Iana-Liza Chervonenko · 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

    Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became 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 conduct fully informed and thorough discussions with colleagues about prioritisation

    Wider context from the report

    “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following: • A delay in obtaining a medical review to the concerning CTG trace. • A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace. • Incorrect documentation in relation to the grading of the caesarean section. • Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient. • The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients. 2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40. The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40. Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40. I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation. I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest. ”

    Source location

    Iana-Liza Chervonenko · 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

    Deficient communication between the medical and midwifery teams

    Wider context from the report

    “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following: • A delay in obtaining a medical review to the concerning CTG trace. • A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace. • Incorrect documentation in relation to the grading of the caesarean section. • Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient. • The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients. 2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40. The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40. Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40. I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation. I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest. ”

    Source location

    Iana-Liza Chervonenko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Exeter and Greater Devon

    AI-generated summary

    Robert Alan 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

    Robert Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.

    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 patient's total number of falls to all visiting staff

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

    Source location

    Robert Alan JONES · 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

    Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.

    Verbatim wording from the response

    “(1) Revise the Trust’s falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 January 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.

    Verbatim wording from the response

    “The Trust’s falls policy (enclosed) has been revised to include information relating to the frequency and duration of neurological observations (in line with the relevant NICE guidelines) and published on the Trust’s policy website. The Trust’s policy includes a post falls checklist (enclosed) which details how often and for how long neurological observations should be recorded. The Trust’s bedside handover and safety briefing standard operating procedure clearly identifies information relating to patient falls (including their risk of falls) is a key component in shift to shift communication, and must be included in handover. Bedside handovers are audited via observation and reports and actions provided to wards and teams where there are gaps in information being shared. Improvement is measured by re-audit.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 January 2015

    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 filing of post-falls checklists with physiological and neurological observation charts for daily multidisciplinary team review of patients’ multiple falls.

    Verbatim wording from the response

    “As per (1), this information is included in safety briefings, which are multi-disciplinary events. Additionally, the Trust’s post falls checklist allows staff to record multiple falls on the same document, ensuring that information relating to falls is held in a central place. The trust is implementing a system that requires the post falls checklist to be filed with the patient’s physiological observations / neurological observations chart, which is reviewed by the Multi Disciplinary Team on a daily basis.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 2 · response
    Published 21 January 2015

    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

    Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.

    Verbatim wording from the response

    “To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 2 · response
    Published 21 January 2015

    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 recommended safety actions are primarily the responsibility of the hospital trust.

    Verbatim wording from the response

    “The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

    Source location

    2015-0068-Response-by-The-Health-Centre
    Page 1 · response
    Published 21 January 2015

    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 hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.

    Verbatim wording from the response

    “The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

    Source location

    2015-0068-Response-by-The-Health-Centre
    Page 1 · response
    Published 21 January 2015

    Open published response

  8. Blackpool and the Fylde

    AI-generated summary

    Freda Virginia Owens · 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

    Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide relevant patient information to involved medical professionals

    Wider context from the report

    “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons: 1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was. 2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved. 3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess. 4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved. These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome. ”

    Source location

    Freda Virginia Owens · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate clinical assessment information between relevant specialist teams

    Wider context from the report

    “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons: 1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was. 2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved. 3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess. 4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved. These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome. ”

    Source location

    Freda Virginia Owens · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Leicester City and South Leicestershire

    AI-generated summary

    Gillian Crossley · 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

    Gillian Crossley underwent elective bowel surgery, was discharged home, re-admitted the following day in extremis with bowel necrosis and perforation, and died on 28 March 2013 despite further surgery. The concerns included inadequate documentation, inadequate observation and monitoring, failure to properly assess and plan her discharge, and inadequate communication between those responsible for her care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate communication between those responsible for care and treatment

    Wider context from the report

    “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry: (1) Inadequate documentation (2) Failure to observe and monitor in accordance with Mrs Crossley's needs (3) Failure to properly assess the fitness for discharge and properly plan that discharge (4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley ”

    Source location

    Gillian Crossley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    Thomas Charles TAYLOR · 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

    Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

    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 accurate diabetic status to medical staff

    Wider context from the report

    “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic. When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff. ”

    Source location

    Thomas Charles TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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