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. Manchester North

    AI-generated summary

    Sarah Kiff · 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

    Sarah Kiff experienced repeated consultations for vaginal discharge, urinary symptoms, heavy menstruation and lower abdominal pain before cervical cancer was diagnosed after an urgent referral in July 2013. The cancer had metastasised to the liver and, after treatment and subsequent decline, she suffered a cardiac arrest and died at Fairfield General Hospital on 14 October 2015. The report identified concerns about failure to follow cancer referral guidance, inadequate examination and history-taking, poor record-keeping and communication, lack of continuity of care, reluctance to perform internal examinations, and inadequate processes for reviewing test results.

    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 explicit requirements between medical and nursing teams

    Wider context from the report

    “2. Medical record keeping and communication between the medical and nursing teams was poor. The doctor's were not explicit about what they required the nurse to do in terms of P.V. examination and made assumption that the nurse/s knew what the doctors expected of them. ”

    Source location

    Sarah Kiff · 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

    Use a written high-vaginal-swab protocol requiring cervical-speculum visualization, documentation of findings, and GP review of abnormalities.

    Verbatim wording from the response

    “At that time, it was agreed that any female patient needing assessment who had presented to a male doctor that had concerns about their skills in examination, would be handed over to one of the female GPs. Similarly, where male patients felt uncomfortable about having pelvic examinations performed by a female GP, then the same onward referral protocol would be followed. This agreement has been in place since October 2013. More recent discussions have also concentrated on the methodology for taking high vaginal swabs following your comments, and it has been reconfirmed that these are all done using cervical speculums, so that the cervix is visualized during the test. Any abnormality found by the nursing staff will be highlighted to one of the GPs. The practice now has an agreed protocol for performing HVS.”

    Source location

    2017-0407-Response-by-Stonefield-Street-Surgery
    Page 2 · response
    Published 26 February 2018

    Open published response

  2. Inner North London

    AI-generated summary

    Dawn Patricia GILL · 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

    Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.

    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 suspected illicit drug use and associated ward-leaving risk to nursing staff

    Wider context from the report

    “1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs. ”

    Source location

    Dawn Patricia GILL · 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

    Remind nursing teams to document suspected illicit drug use in care plans and include it in nursing handovers.

    Verbatim wording from the response

    “During her stay in hospital the wider nursing team and medical staff were aware of the suspicion of Ms Gill taking illicit drugs. She had been spoken to by the consultant and charge nurse and the senior nurse to advise this was not acceptable. However the nursing care plan could and should have been more explicit about this, and if it had been nursing staff would have been more aware of her behaviour and the attendant risks. All nursing teams in the hospital are being reminded of the importance of documenting the use of suspected use of illicit drugs in care plans, and of ensuring this information is part of the nursing handover.”

    Source location

    2018-0354-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 25 April 2019

    Open published response

  3. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · 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

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    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 escalating NEWS to medical staff

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Manchester City

    AI-generated summary

    Sheila Winifred Ridgway · 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

    Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.

    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

    Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments

    Wider context from the report

    “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously ”

    Source location

    Sheila Winifred Ridgway · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Somerset

    AI-generated summary

    Robin Damien Richards · 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

    Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

    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 communication with family and between Trust staff

    Wider context from the report

    “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards ”

    Source location

    Robin Damien Richards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Adrian Jennings · 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

    Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.

    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 use one Trust-wide IT system for information sharing between professionals involved in care

    Wider context from the report

    “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care; ”

    Source location

    Adrian Jennings · 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

    Lead the Global Digital Exemplar programme to digitise and connect health systems and improve secure information sharing.

    Verbatim wording from the response

    “In relation to your first concern, we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, led by NHS England.”

    Source location

    2018-0111-Response-by-NHS-England
    Page 1 · response
    Published 17 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with Local Health and Care Record Exemplars to establish local longitudinal records enabling authorised staff to access permitted patient information.

    Verbatim wording from the response

    “In addition, and building on this provider digitisation is the specific focus on enabling access to pertinent information from across venues of care. There has been progress made on this within the service with around 60 local information sharing initiatives that aim to share information across GP, Acute and Social Care settings. Building on this, NHS England will be working with a number of Local Health and Care Record Exemplars that will focus on establishing a local longitudinal record available in their areas to enable authorised staff to access permitted information about a patient’s history of contact with the NHS and related care services in order to support the provision of safe, integrated care.”

    Source location

    2018-0111-Response-by-NHS-England
    Page 2 · response
    Published 17 June 2018

    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

    NHS England leads work to address secure cross-service record sharing and should provide information about its progress.

    Verbatim wording from the response

    “You raise two matters of concern relating to IT, firstly on the lack of a single IT system across the Pennine Care NHS Foundation Trust and its impact on patient information sharing. We recognise there are challenges across the service in enabling secure record sharing and there are a number of steps being taken to address this, led by NHS England. I will leave it to NHS England to advise on the work currently underway around the Global Digital Exemplar Programme and the Local Health and Care Record Exemplars that are designed to join up and digitise health systems, providing clinicians with timely access to patient clinical information.”

    Source location

    2018-0111-Response-by-Department-of-Health
    Page 2 · response
    Published 17 June 2018

    Open published response

  7. Black Country

    AI-generated summary

    Mr Frank Hayward · Prevention of Future Deaths report

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

    Report summary

    Mr Frank Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.

    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

    Poor communication between the Orthotics Department and ward-based staff

    Wider context from the report

    “2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff. In addition there was a significant delay in obtaining an urgent CT scan. ”

    Source location

    Mr Frank Hayward · 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 all Sandwell General Hospital wards with Orthotics contact details and substantive administrative support for timely referrals.

    Verbatim wording from the response

    “At the time when Mr Hayward required a collar, the Orthotics Department was in the process of relocating onto the Sandwell General Hospital (SGH) site. This move, together with issues of transfer of telephone numbers and locum staff, delayed the referral being received and acted upon. All wards at SGH now have the contact details (number and email address) of the Orthotics Department to ensure contact is timely, with substantive administrative staff in place. Business Continuity plans are in place but are being reviewed to take account of staffing levels, given that this was a concern at the time of Mr Haywards admission.”

    Source location

    Frank-Hayward-Response
    Page 2 · response
    Published 29 March 2018

    Open published response

  8. Manchester West

    AI-generated summary

    William Myers · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to circulate important clinical risk information to treating clinicians

    Wider context from the report

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

    Source location

    William Myers · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce the approved PARIS electronic clinical record system across Manchester services.

    Verbatim wording from the response

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

    Source location

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

    Open published response

  9. Surrey

    AI-generated summary

    Ernest Wayne 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

    Ernest Wayne Smith was found deceased in woodland at Chelsham Common, Warlingham, on 13 June 2016. The inquest concluded that the medical cause of death was hanging and recorded a short-form conclusion of suicide. Concerns included failures to arrange or follow up medication reviews and the absence of a clear system for updating GPs about missed appointments and disengagement where the CMHRS medical team was not involved.

    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

    Lack of a clear system for updating GPs about patient disengagement when the medical team is not involved in care

    Wider context from the report

    “- There are a number of CMHRS service users who, like Mr Smith, are not under the CMHRS medical team, but whose care is led by other members of the multi-disciplinary team, including clinical psychologists and care co-ordinators. The court heard that there is a clear system in place in the medical team for updating GPs on progress and also in the event of failures to attend appointments (DNAs). However, it did not appear to the court that there was a clear system for updating GPs when the medical team was not involved in a patient’s care. This risks GPs being unaware, as ████████ was in this inquest, of instances in which their patient begins to display signs of disengagement with the service. ”

    Source location

    Ernest Wayne Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create an action plan addressing the concerns raised in the PFD report.

    Verbatim wording from the response

    “The PFD report has been carefully considered and discussed by the Trust’s Adult Mental Health Division, within which the Community Mental Health Recovery Services are located. The Division has created the attached action plan, which outlines the actions that the Division is going to take in order to address your concerns. I hope the action plan is self explanatory.”

    Source location

    2017-0459-Response-by-Surrey-NHS-Trust
    Page 1 · response
    Published 22 December 2017

    Open published response

  10. Manchester West

    AI-generated summary

    Patricia Forshaw · 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

    Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.

    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 relevant preliminary examination information to Doctors

    Wider context from the report

    “ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20th October 2016 and the advice to give paracetamol was not recorded in any Hospital records. Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased. The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor. ████████ commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw. ”

    Source location

    Patricia Forshaw · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reinforce nurses’ recording of relevant care and notification of reviewing clinicians, including through local nursing induction.

    Verbatim wording from the response

    “All of our nurses are aware of their duty to ensure patient records are accurate and to document relevant information as appropriate. However I understand that a notification has been circulated to all nursing staff by the Matron for Unscheduled Care to reiterate the requirement for nurses to document in the patient’s notes any relevant care or treatment provided. The Clinical Director for Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at the Clinical Governance Meeting. I have also been informed that this notification will be incorporated into the ongoing local induction for nursing staff.”

    Source location

    2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 3 · response
    Published 2 November 2017

    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