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 South

    AI-generated summary

    David Michael little · 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

    David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

    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 radiology staff and clinicians and nurses

    Wider context from the report

    “4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses. There was little or no good communication with the family which led to additional distress for them at a time of great sorrow. ”

    Source location

    David Michael little · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

    Verbatim wording from the response

    “Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.”

    Source location

    2016-0237-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 28 June 2016

    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

    Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

    Verbatim wording from the response

    “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.”

    Source location

    2016-0237-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 28 June 2016

    Open published response

  2. Surrey

    AI-generated summary

    Mr Critall · 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 Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 of the post-procedure care plan to ward staff

    Wider context from the report

    “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

    Source location

    Mr Critall · 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

    Develop a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.

    Verbatim wording from the response

    “2. A patient pathway has been developed for patients undertaking this type of procedure to ensure improved communication between staff on the ward and in radiology. The pathway ensures base line observations are recorded prior to and following the procedure and requires clear communication on handover.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    Open published response

  3. Preston and West Lancashire

    AI-generated summary

    Sally Ann Tooze Froggatt · 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

    Sally Ann Tooze Froggatt died on 6 April 2015 at Royal Lancaster Infirmary following multiple missed opportunities to treat her high risk of venous thromboembolism. Concerns included failures in the Duty of Candour, inadequate staff training, potentially contradictory pharmacy guidance, and failure to raise known risk factors with consultants.

    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 staff to raise known risk factors with consultants

    Wider context from the report

    “4. failure of BMI nursing staff to raise known risk factors with consultants ”

    Source location

    Sally Ann Tooze Froggatt · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 clinical staff

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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

    Require clinical handovers to access microbiology results through ICE and document outstanding results for follow-up and action.

    Verbatim wording from the response

    “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    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 staff receiving urgent blood results by telephone to record, sign, date, time and verbally communicate them to medical staff.

    Verbatim wording from the response

    “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response

  5. Manchester West

    AI-generated summary

    Mollie Bentham · 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

    Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

    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 medical staff to liaise about patient concerns and clinical attendances

    Wider context from the report

    “1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”

    Source location

    Mollie Bentham · 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

    Recruit and place a permanent full-time doctor at Darley Court Intermediate Care.

    Verbatim wording from the response

    “The Trust recently recruited a permanent doctor to Darley Court Intermediate Care (IMC) on a full time basis and this doctor is now in post. Prior to the commencement of ████████ the medical cover had been provided by locum doctors on long term contracts. I believe this permanent arrangement will enhance communication between the medical and nursing teams and provide continuity of care for patients. The level of consultant cover has also been reviewed and it is planned to increase the number of sessions a consultant will attend Darley Court IMC from the current provision of two sessions per week.”

    Source location

    Mollie-Bentham-Response
    Page 1 · response
    Published 30 December 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

    Increase consultant attendance sessions at Darley Court Intermediate Care beyond the existing two sessions per week.

    Verbatim wording from the response

    “The Trust recently recruited a permanent doctor to Darley Court Intermediate Care (IMC) on a full time basis and this doctor is now in post. Prior to the commencement of ████████ the medical cover had been provided by locum doctors on long term contracts. I believe this permanent arrangement will enhance communication between the medical and nursing teams and provide continuity of care for patients. The level of consultant cover has also been reviewed and it is planned to increase the number of sessions a consultant will attend Darley Court IMC from the current provision of two sessions per week.”

    Source location

    Mollie-Bentham-Response
    Page 1 · response
    Published 30 December 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

    Provide Darley Court staff direct access to an out-of-hours GP and require consultation details to be documented in Darley Court medical notes.

    Verbatim wording from the response

    “The Darley Court staff now have direct access to an Out of Hours (OOH) General Practitioner (GP) who is attached to the Admission Avoidance Team (AAT). The GP is with the AAT from 18:30 to 22:00 Monday to Friday and 9:00 to 22:00on Saturday and Sunday. Patients that require urgent medical attention outside of the hours of medical cover by the doctor at Darley Court but within the hours stipulated above will be seen by the OOH GP based at the AAT. It has been agreed with BARDOC (OOH GP Provider) that the GP will document details of the consultation in the medical notes at Darley Court. This will ensure that both the nursing and medical staff are informed of the treatment plan for the patient. I understand that this service has been utilised and positive feedback has been received from staff at Darley Court.”

    Source location

    Mollie-Bentham-Response
    Page 1 · response
    Published 30 December 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

    Include the doctor and a senior therapy-team member in the daily morning safety huddle.

    Verbatim wording from the response

    “Standard Operating Procedures (SOP) have been developed with regard to improving the handover of information. The Daily Safety Huddle which takes place every morning now includes the doctor and a senior member of the therapy team. In addition, the senior Sister at Darley Court has been reviewing the efficiency of the handover process at the end of and commencement of a shift. Further improvements are identified these will be included in the SOP for handovers.”

    Source location

    Mollie-Bentham-Response
    Page 2 · response
    Published 30 December 2015

    Open published response

  6. Black Country

    AI-generated summary

    Mr Frank Mellers · 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 Mellers fell at home on 4 September 2015, fractured his left hip, and was admitted to hospital for surgery. He suffered a cardiac arrest on 17 September 2015 and died that day from congestive cardiac failure, with ischaemic heart disease and the post-operative fracture repair recorded as contributing factors. The concerns included poor communication with his family about his DNAR status and poor communication between nursing and medical staff, including CPR being commenced despite a DNAR being in place.

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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 nursing and medical staff to communicate DNAR decisions

    Wider context from the report

    “(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions. (2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. ”

    Source location

    Mr Frank Mellers · 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

    Reiterate the ward-round standard requiring daily joint nursing and medical staff rounds.

    Verbatim wording from the response

    “• We have reiterated the importance of the use of our ward round standard which emphasises the importance of daily ward rounds to be carried out between both staff groups to ensure strong and robust care management.”

    Source location

    Frank-Mellers-Response
    Page 2 · response
    Published 17 November 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

    Develop a Ward Board indicator highlighting patients with DNAR decisions for staff handovers and ongoing reference.

    Verbatim wording from the response

    “• We have developed an indicator on our Ward Boards to ensure that where a patient has a DNAR in place it is highlighted to all staff. The Ward Boards act as a communication tool to allow for fast reference by all staff groups during handovers and during the course of the day.”

    Source location

    Frank-Mellers-Response
    Page 2 · response
    Published 17 November 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

    Review the DNAR policy for compliance with best practice, including communication requirements.

    Verbatim wording from the response

    “• We reviewed our policy to ensure that it is compliant with best practice (including communication) with regard to DNAR.”

    Source location

    Frank-Mellers-Response
    Page 2 · response
    Published 17 November 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

    Conduct peer audits of DNAR form use and continue reviewing them on a rolling basis to assure implementation of disseminated learning.

    Verbatim wording from the response

    “• We have undertaken over the past several months a series of peer audits throughout a variety of care settings to review the effectiveness with which DNAR forms are being utilised. I am pleased to report that during this period we have seen significant improvements in the quality, completeness and robustness of the use of DNAR with particular emphasis placed upon ensuring discussions with patients and their families are clear and fully documented about the purpose and potential outcome of a DNAR. We will be carrying out these audits and reviews on a rolling basis to assure that the learning from this incident which we have disseminated across our organisation.”

    Source location

    Frank-Mellers-Response
    Page 2 · response
    Published 17 November 2015

    Open published response

  7. Leicester City and South Leicestershire

    AI-generated summary

    Alan Tear · 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

    Alan Tear was receiving palliative treatment for cholangiocarcinoma and died after a biliary drain insertion. He died from an intraperitoneal bleed caused by a misplaced drain and peritoneal perforation. Concerns included missed post-operative observations, failure to report a rising EWS to medical staff, and unclear communication between the interventional radiology and nursing teams.

    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 clarity in communication between the Intervention Radiology team and nursing staff about observations to be carried out

    Wider context from the report

    “3. It was not clear that the Intervention Radiology team knew or understood what observations the nursing staff would carry out and the communication between the teams needs to be reconsidered. ”

    Source location

    Alan Tear · 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

    Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.

    Verbatim wording from the response

    “As a result of this inquest we will be redesigning the sheet which documents the required frequency of observations to be undertaken on the receiving ward. The sheet and required frequency will vary according to the type of the procedure performed. To optimise the hand over the sheet will be signed by the Interventional radiology nurse and receiving ward at the radiology theatre. Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015.”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 2 · response
    Published 14 October 2015

    Open published response

  8. Inner South London

    AI-generated summary

    Lee Mark Anthony Bates · 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

    Lee Mark Anthony Bates died at 01.18 on 24 February 2014 in Cambian Churchill London Clinic after ingesting a potentially fatal overdose of Zopiclone in conjunction with benzodiazepines while under one-to-one eyesight observation. The principal concerns were inadequate staff training in one-to-one observation and insufficient coordination between psychiatric and sleep-apnoea specialists about CPAP use, sedative medication risks, and monitoring of patients with severe obstructive sleep apnoea.

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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 establish dialogue between specialist physicians and psychiatrists about managing OSA risks

    Wider context from the report

    “The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of not doing so and the risks of sedative medication especially if not using it and the desirability of oximetry. ████████ director of the hospital, said that there was no guidance from GSTT about the use of the CPAP machine, of which psychiatric staff would not be familiar. He presumed that none of the psychiatrists sought guidance about medication, observation or use of the machine in a patient with severe sleep apnoea, as they did not see the need. He expected that the sleep clinic would provide any advice that psychiatrists needed in managing the OSA in a psychiatric unit. ████████ consultant psychiatrist at Cambian, acknowledged that there were risks of death to people with severe OSA given drugs and then not taking CPAP. Physical health care needs were advised by GPs. He said that psychiatric staff did not know about the importance of CPAP, nor whether introduction of a drug required monitoring. There is the facility to use pulse oximetry in the hospital, but the implications, if it were to be used in all OSA patients, would need to be considered. There are many OSA patients in Cambian. It is clear that there is an on going risk of avoidable death in patients with OSA in Cambian Churchill hospital (especially if severe and associated with morbid obesity), Although this risk is reduced by use of CPAP machine and increased by use of sedative drugs, and may be mitigated by use of oximetry, such measures require dialogue between specialist physicians and psychiatrists and might require special provision for monitoring of patients that are high risk and require sedation. Neither hospital has addressed how this dialogue is to be instigated when required, nor how these risks should be addressed; reliance on GP advice seeming to be insufficient. ”

    Source location

    Lee Mark Anthony Bates · 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

    Agree a protocol with St Thomas’ to improve communication and care coordination for patients referred to physical health clinics.

    Verbatim wording from the response

    “With that in mind, and following the inquest into the death of Mr Bates when you indicated your proposal to make this report, my hospital manager at Cambian Churchill Hospital has met with ████████ at St Thomas’ and agreed a protocol going forward to cover the matter set out in the attached document, in order to reduce the possibility of inadequate communication or care in the future.”

    Source location

    2015-0381-Response-by-Cambian-Group
    Page 1 · response
    Published 17 September 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

    Responsibility for physical-health care after referral is transferred to St Thomas’ specialists, over whom the hospital has no control.

    Verbatim wording from the response

    “Your Report raises an issue in relation to communication between our hospital and the sleep apnoea clinic at St Thomas’. As you will appreciate, the clinic is operated by Guys and St Thomas’ NHS Foundation Trust which is separate from our hospital. We therefore clearly have no control over them, and vice versa.”

    Source location

    2015-0381-Response-by-Cambian-Group
    Page 1 · response
    Published 17 September 2015

    Open published response

  9. Avon

    AI-generated summary

    Mr. Masoud Ghaderi · 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. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.

    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

    Ward-round planning and preparation relying solely on a brief nursing summary

    Wider context from the report

    “(3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward rounds. The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions . ”

    Source location

    Mr. Masoud Ghaderi · 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

    Review nursing models of care and generate recommendations for a standardised care-delivery model.

    Verbatim wording from the response

    “When undertaking ward rounds, the care team have access to the patients full and comprehensive care record. However, it is accepted that there are occasions when the nursing summary is not as comprehensive as it should be. A full review of nursing models of care is to be undertaken by the Nursing Directorate with recommendations generated for a standardised model of care delivery (i.e. named professional / team nursing structure). This will facilitate a more comprehensive recording of a patients presenting needs state at any given time. Also a review of the existing multi professional weekly review meetings has been undertaken. The findings and recommendations will be taken to the Integrated Governance Group, chaired by the Executive Director of Nursing and Quality in October 2015. The review was completed by the Heads of Quality for each of the six local delivery units.”

    Source location

    2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 3 · response
    Published 17 July 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

    Ward rounds have access to the patient's full comprehensive care record and do not rely solely on the nursing summary.

    Verbatim wording from the response

    “3. The Trust has a comprehensive single care record for each service users. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward round. The Trust should review its planning and preparation for ward rounds so that reliance is not paced solely on a brief summary with the inherent risk of errors and omissions.”

    Source location

    2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 3 · response
    Published 17 July 2015

    Open published response

  10. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Arthur Lindsay Fry · 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

    Arthur Lindsay Fry was diagnosed with a glioblastoma and underwent tumour debulking surgery on 14 April 2014. He developed severe neurological complications, including a subdural haematoma and extensive brain infarction, and died on 17 April 2014. The principal concern was a breakdown in communication that led to a planned MRI scan not being carried out, which may have impacted his 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

    Failure to communicate additional safety and consent requirements for procedures

    Wider context from the report

    “During the course of the inquest I heard evidence that an MRI scan had been scheduled for 15th April 2014 because of a down turn in the deceased's condition. He was taken to the MRI scanning department but he was declined for scanning by the radiographer because an issue over safety and a further consent form was required by two doctors. This requirement was not made known to the consultant or his team and there was a breakdown in communication. The failure to carry out the MRI scan may have impacted upon the deceased's care. Tighter controls concerning the requisitioning of procedures (in this case MRI and CT scans) need to be designed to avoid confusion and potential failures to carry out the procedures. I am aware that some recommendations have been put forward but I would like to be sure that they are being implemented. ”

    Source location

    Arthur Lindsay Fry · 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

    Document accompanying nurses and explicit ward instructions in the electronic CRIS system for imaging communication.

    Verbatim wording from the response

    “Within her report and from evidence given by ████████ Consultant Radiologist, it was heard that radiologists have taken steps to improve communication between the imaging department and ward areas. It was explained that all radiographers now document the name of the accompanying nurse and explicit instruction for the ward clinical team are entered into the electronic CRIS system. At the time of the inquest, ████████ also made suggestions for improvement and we are able to provide the following update in relation to the progress that has been made.”

    Source location

    2015-0258-Response-by-University-Hospitals-North-Midalnds-NHS-Trust
    Page 2 · response
    Published 7 July 2015

    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