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. Avon

    AI-generated summary

    Calogero Di Blasi · 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

    Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.

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    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 of specialty teams to communicate investigation information and share results in a timely manner

    Wider context from the report

    “(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur. Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out. ”

    Source location

    Calogero Di Blasi · 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

    Scope administrative review of patient lists to identify parallel clinical pathways before endoscopy and assess a possible pilot.

    Verbatim wording from the response

    “I asked ████████ and the witnesses to consider whether any further action could be taken to strengthen the pre-procedure checklist. I am advised that they have identified an additional potential change in practice. The Division of Surgery will undertake a scoping exercise to assess the feasibility of the administrative teams reviewing the patient list and identifying any patients who are on a parallel clinical pathway. The endoscopist would then be notified to review the electronic records and ICE and any relevant investigations before the procedure. Upon completion of the scoping exercise, the Division will consider whether a pilot may be offered for the endoscopy team.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Discontinue paper radiology reports from 1 May 2024.

    Verbatim wording from the response

    “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 3 · response
    Published 21 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Set up specialty-specific radiology reporting systems within existing digital platforms.

    Verbatim wording from the response

    “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 3 · response
    Published 21 November 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Launch a joint digital strategy to converge provider-collaborative IT systems and centralise clinical information digitally.

    Verbatim wording from the response

    “UHBW and NBT will shortly appoint a joint Chief Executive and Chair. The Chief Digital Information Officer has already been appointed across both Trusts and is in the process of launching a Digital Strategy, with the aim of converging the IT systems across the provider collaborative.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 4 · response
    Published 21 November 2023

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Local management and implementation of national policies and procedures is assigned to NHS England and the responsible Integrated Care Board.

    Verbatim wording from the response

    “In preparing this response, Departmental officials have made enquiries with NHS England. The matters of concern you raise relate to the local management and implementation of national policies and procedures. As such, I requested NHS England liaise with the North Somerset and South Gloucestershire Integrated Care Board (ICB) responsible for University Hospitals Bristol and Weston NHS Foundation Trust.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 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

    Existing clinician checks provide a robust process for identifying relevant investigations for patients on parallel clinical pathways.

    Verbatim wording from the response

    “As many patients are treated out of the region or in private or satellite institutions, the subsequent check by the clinician, through a discussion with the patient, provides another opportunity to identify relevant investigations, thereby ensuring there is a robust process in place.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    Open published response

  2. Newcastle and North Tyneside

    AI-generated summary

    Brian David MORETON · 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

    Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

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    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 clinically important information between clinicians and departments

    Wider context from the report

    “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

    Source location

    Brian David MORETON · 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

    Participate in a regular Inflammatory Bowel Disease multidisciplinary team meeting at Newcastle to improve communication and advice between the Trusts.

    Verbatim wording from the response

    “If specialist advice is required in relation to the management of colitis and any potential complications arising from this, even when the colitis is as a result of immunotherapy for the treatment of a melanoma, advice would be sought by the treating Gastroenterology team at North Cumbria, from the Gastroenterology team at Newcastle (as the tertiary centre), as the Gastroenterologists are the specialists dealing with colitis and any complications arising from this. This is why, following Mr Moreton's death, North Cumbria now take part in a regular Inflammatory Bowel Disease MDT at Newcastle, which as you heard at the inquest, has improved communication between the two Trusts and enables clinicians to more freely pick up the phone and seek advice.”

    Source location

    Response from DAC Beachcroft
    Page 1 · response
    Published 5 October 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

    Verbatim wording from the response

    “Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within various policies and SOPs, it would appear that this system has lost momentum within the Trust. SBAR is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to achieve this. Clinicians will be expected to utilise SBAR in any escalation of a clinical problem that requires attention, or to facilitate efficient handover, both internally and externally.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.

    Verbatim wording from the response

    “The Trust now holds joint biweekly IBD multidisciplinary team meetings (MDTs) between the internal general surgery and gastroenterology teams. A triweekly joint specialist IBD MDT between the Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust has also been established since February 2023. An MDT, made up of a variety of specialists within an interest in IBD or gastroenterology, approach to the management of a patient’s IBD, is recommended to provide optimised and personalised care, based on available professional expertise, infrastructure and funding, and helps to prevent errors in the delivery of care and avoid related harm to patients. The timing of MDT meetings happen on the aforementioned frequencies to ensure decision-making is not delayed, however, such discussions largely relate to complex, chronic IBD patients.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.

    Verbatim wording from the response

    “Acute or emergency care decisions cannot not be delayed for timetabled MDTs, but should happen separately between relevant specialists. The introduction of the MDTs has improved working relationships and communication between the teams and Trusts, to ensure early referrals for specialist input in the management of a patient’s care is sought, for patients who are acutely unwell and/or where urgent advice is required. Had the MDTs been in place during Mr Moreton’s admission, he likely would have been listed for discussion in both MDTs and professional relationships would have been established to seek earlier input from surgical colleagues and specialists in Newcastle.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Sinon MASHA · 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

    Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Fragmented communication between professionals involved in birth-choice planning

    Wider context from the report

    “2. Specifically, Section 5 of the Birth Choices Guidance include: “5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices. ... 5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged. 5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated. 5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.” 3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk. 4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife. 5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk. ”

    Source location

    Sinon MASHA · Prevention of Future Deaths report
    Page 1 · 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

    Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.

    Verbatim wording from the response

    “• A Bi-weekly MDT meeting is in place with joint discussion and planning separately with the named consultant.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.

    Verbatim wording from the response

    “• There is a plan to agree allocated Consultant (either Delivery suite lead or Antenatal clinic lead) to regular MDT meetings. This is contingent on the current consultant job planning (due for completion by 31 August 2023). Following job planning this action will be completed before the 31 October 2023.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.

    Verbatim wording from the response

    “• A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

    Open published response

  4. Inner North London

    AI-generated summary

    Hilary Clare (Billy) Guedalla · 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

    Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

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    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 leave restrictions to all unit staff

    Wider context from the report

    “2. The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made. ”

    Source location

    Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
    Page 4 · concerns

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    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 relevant ward-round risk information to all unit staff

    Wider context from the report

    “3. The relevant information gathered during the Ward Round on the 28th October 2021, which included the fact that the deceased had attempted to take their own life, the night before, was not adequately communicated to all staff on the unit. ”

    Source location

    Hilary Clare (Billy) Guedalla · 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

    Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.

    Verbatim wording from the response

    “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Send ward staff a memo reinforcing requirements to record and communicate clinical decisions about patient leave.

    Verbatim wording from the response

    “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 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

    Include leave-recording and information-sharing requirements in the junior doctor induction programme.

    Verbatim wording from the response

    “Additionally, the Clinical Director for City and Hackney has updated the junior doctor induction programme to include this information.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.

    Verbatim wording from the response

    “In order to provide an additional safety net to ensure that appropriate information sharing occurs, a daily Safety Huddle comprised of the entire multi-disciplinary team now takes place on all City and Hackney inpatient wards each morning. Critical clinical information about all service users is shared during the Safety Huddles. Important clinical decisions and risk information discussed at the Safety Huddles are expected to be documented on RIO (this expectation will also be further reinforced at the away day and junior doctor induction).”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.

    Verbatim wording from the response

    “Additionally, all inpatient leave arrangements (for both formal and informal service users) are now documented on the relevant nursing office whiteboard in each City and Hackney inpatient ward. The leave arrangements are reassessed at every shift handover and the whiteboard is updated accordingly. It is expected that all staff members check the whiteboard before allowing leave of any type.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    Open published response

  5. Surrey

    AI-generated summary

    Louis James Rogers · 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

    Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.

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    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 make paramedic information available to all clinicians

    Wider context from the report

    “5. Febrile Seizure Pathway Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management. ”

    Source location

    Louis James Rogers · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Essex

    AI-generated summary

    Doris Joyce Smith · 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

    Doris Joyce Smith fell on Ruby Ward on 9 October 2020, suffered a traumatic subarachnoid haemorrhage, and died on 14 October 2020. The report identifies concerns about delayed and inaccurate falls risk assessments, inadequate neurological and ward observations, failure to implement physiotherapy advice, poor record keeping, and ineffective communication about the care and observation levels required.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of effective communication about required care, treatment and observation levels

    Wider context from the report

    “(6) Lack of effective communication as to the care and treatment required for Doris Smith between Trust staff and the levels of observations required to keep her safe on the ward ”

    Source location

    Doris Joyce Smith · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure physiotherapy input at daily safety huddles, including communication of observation requirements and risk-mitigation plans.

    Verbatim wording from the response

    “- The unit physiotherapist attends the daily safety huddle to ensure effective communication within and between the clinical team. Where this is not possible, the physiotherapy assistant attends to provide a handover of assessments and plans and to receive updates on any patients requiring physiotherapy input. During these meetings, the physiotherapist or their assistant will contribute to discussion around requirement for observation and other risk mitigating interventions. Any changes to the patient’s care are communicated with the team and are updated within the clinical records, and the mobility poster displayed in their bed area where relevant.”

    Source location

    Response from Essex Partnership University
    Page 4 · response
    Published 7 March 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Display and maintain patient-bedroom mobility-assistance posters, updating and communicating them when mobility needs change.

    Verbatim wording from the response

    “- Posters are displayed in patient bedrooms to clearly inform the patient and supporting staff of the mobility assistance they require, and includes details of aids they may require for the hearing and visual needs. The posters are initiated by physiotherapy staff and updated by them or the occupational therapy staff. When an update is completed, this is emailed to the team, updated within the clinical records, discussed at the safety huddle and handover. This ensures prompt and thorough communication sharing. This was in place at the time Doris was an inpatient and remains current practice.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 7 March 2023

    Open published response

  7. East London

    AI-generated summary

    Peter Mantador Ross · Prevention of Future Deaths report

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

    Report summary

    Peter Mantador Ross sustained a subdural haemorrhage and cervical spine fracture after falling down stairs at home on 8 July 2020. The spinal fracture was misinterpreted and remained undiagnosed; later failures to maintain immobilisation and delays in MRI contributed to cardiac arrest and severe neurological injury. He subsequently developed pneumonia following an aspiration episode, and the inquest found that neglect contributed to his death. Concerns also included failures to review and communicate CT findings and poor clinical record-keeping.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Repeated failures in communication between clinical teams and staff

    Wider context from the report

    “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal. 2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician. 3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images. 1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal. 2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician. 3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images. 4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross. 5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross. ”

    Source location

    Peter Mantador Ross · 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

    Provide non-consultant clinical staff training in authoritative reporting, empowerment and escalation, including formal induction for new doctors.

    Verbatim wording from the response

    “The neurosurgery department has reflected on this finding and will be providing training to all non-consultant grade clinical staff in authoritative reporting as well as support with techniques regarding empowerment and escalation to ensure that any future concerns are raised to the appropriate responsible consultant. This training will focus on resilience, good communication and empowerment to speak out or challenge areas of potential failings. The department will closely monitor training outcomes for success (at LFG and M&M meetings) and will implement formal training as part of local induction for new doctors.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 2 · response
    Published 7 November 2022

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop improved multidisciplinary communication through cross-disciplinary meetings, agreed action planning and hybrid meeting formats.

    Verbatim wording from the response

    “4) The department has reflected on this finding and is developing better communication methods with all stakeholders and colleagues. This includes inviting clinical colleagues to local M&M, MDT and Clinical Governance meetings to discuss cases that include multiple disciplines for learning and agreed action planning. MDT’s are now in a hybrid format which incorporates virtual and face to face meetings offering flexibility for a wider range of stakeholder attendance.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 2 · response
    Published 7 November 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

    Implement an electronic patient record system to improve access to records, communication, decision-making and patient planning.

    Verbatim wording from the response

    “orientation of our records system. The Trust is currently in the process of implementing electronic patient record system. The purpose of the new system is to provide clinicians with an easier to access tool to aid good communication, decision making and clear patient planning.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals
    Page 3 · response
    Published 7 November 2022

    Open published response

  8. 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 share iliac artery aneurysm information to trigger Consultant Vascular Surgeon advice

    Wider context from the report

    “(4) The Consultant Haematologist confirmed that if information of the existence of an Iliac Artery Aneurysm had been shared, they would have sought the advice of a Consultant Vascular Surgeon. ”

    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

    Communicate the requirement for accurate information in clinician referrals through clinical directors and regular team training.

    Verbatim wording from the response

    “We accept that the importance of any referral made by a clinician should contain accurate information so that it is understood and acted upon by the responsible clinician. This has been communicated with the clinical directors who have disseminated this information to their clinical teams. In addition to this, it is also being communicated through the training sessions which are delivered to the clinical teams regularly.”

    Source location

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

    Open published response

  9. East London

    AI-generated summary

    Shahan Abu Aman · 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

    Shahan Abu Aman, a three-year-old boy, attended hospital on 7 December 2021 with vomiting and diarrhoea and was discharged after assessment, observation and a fluid challenge. He was found unresponsive the following morning and died in hospital; the report identified miscommunication between nursing and medical staff, failure to confirm the most recent observations and PEWS score before discharge, and a pressurised emergency department environment as concerns.

    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 of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge

    Wider context from the report

    “1. A series of miscommunications between; nursing staff, junior and consultant paediatric medical staff resulted in concerns regarding Aman not being properly considered prior to discharge. Staff relied on assumptions that others understood the factors affecting Aman and had a plan to resolve them, this was not the case. Had effective communication occurred it was unlikely that Aman would have been discharged. ”

    Source location

    Shahan Abu Aman · 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 use a two-hourly Paediatric SITREP to record, escalate and plan responses to staff concerns despite low PEWS.

    Verbatim wording from the response

    “The Paediatric Emergency Department has now implemented and is using a detailed 2 hourly SITREP (Situational Report). The SITREP aims to capture this exact concern from members of staff who are worried about a patient who, despite the psychological parameters being abnormal, the early warning score does not identify this concern.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 10 October 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

    Reinforce the importance of communicating clinical concerns through emergency-department forums, senior nursing discussions and junior-doctor induction.

    Verbatim wording from the response

    “The severity of this case was also personally discussed and fed back by the Clinical Director of the Emergency Department and by the Consultant in Paediatric Emergency Department at various forums. Within these forums the importance of communication was strenuously emphasised.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 10 October 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

    Provide ongoing teaching on paediatric gastroenteritis risks, deterioration despite low PEWS and communicating concerns.

    Verbatim wording from the response

    “also acknowledged. With this in mind, the evidence bundle which has already been provided, demonstrates all the teaching and educational efforts that we have put in place and continue to provide; highlighting the importance of this case. Within these teaching modalities, although not explicitly mentioned, the emphasis on communicating concerns remains a rolling theme.”

    Source location

    Response from Barts Health NHS
    Page 3 · response
    Published 10 October 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

    Share serious-incident reports, learning summaries and lessons through clinical, divisional and hospital governance forums.

    Verbatim wording from the response

    “This case and its investigation have also fed into the Trust’s robust clinical governance process that emphasises learning from incidents and a just culture. This as well as all serious incident investigations conclude with actions to ensure final reports are shared with relevant clinical staff for their reflective learning. Learning summaries are also completed for all investigations and this is shared across all hospitals within the Trust for learning. These steps have all taken place with respect to this case.”

    Source location

    Response from Barts Health NHS
    Page 3 · response
    Published 10 October 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 incident is considered isolated and not evidence of an inherent systemic process failure.

    Verbatim wording from the response

    “While acknowledging the seriousness of the highlighted concerns, it is important to note that this incident occurred on the background of a department that saw 150,487 patients; of which 37,146 were children in the year 2021. We do not believe that there is an inherent systemic process failure; however, we have introduced controls as outlined below which are designed to minimise the risk of recurrence of this tragic outcome.”

    Source location

    Response from Barts Health NHS
    Page 1 · response
    Published 10 October 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

    Existing communication-failure messaging is continuously reinforced through induction and departmental practice.

    Verbatim wording from the response

    “Over and above what has been mentioned, the theme of communication failure was not just aimed at the Paediatric Nursing team but is one that the Clinical Director himself personally emphasises; and has done so for at least 7 years at the junior doctor’s induction programme. The department feels confident that its messaging regarding the risks of communication failure are constantly reinforced.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 10 October 2022

    Open published response

  10. Manchester South

    AI-generated summary

    Philip 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

    Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and 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

    Delays in consultants communicating diagnostic and treatment information after appointments or assessments

    Wider context from the report

    “3. The Inquest heard that there were delays in communications from consultants to other clinicians e.g. GPs and patients following appointments/assessments due to a shortage of administrative support for consultants. This meant that important diagnostic/treatment information about patients was not shared expeditiously. ”

    Source location

    Philip 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

    Build digital infrastructure using artificial intelligence, automation and video-call technologies to support NHS services.

    Verbatim wording from the response

    “I also note your concern that incompatible IT systems between the hospitals in question made communication and information sharing in relation to Mr Jones’s treatment more difficult, as did the delay in the consultants communicating with other clinicians, including GPs, and as well as the patients themselves. I recognise that there needs to be adequate administrative support and greater use of digital technology to assist healthcare workers in completing non-clinical tasks, and that could increase the time they can spend caring for patients. This would provide a better patient experience and, ultimately, improve health outcomes.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 October 2022

    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