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. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

    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 liaison between dermatologists and other consultants about Hydroxychloroquine toxicity

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Wales Central

    AI-generated summary

    Khuong Lam · 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

    Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.

    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 inform the responsible clinician of ward transfers

    Wider context from the report

    “(3) ████████ the RC told the inquest that if he had been made aware of Khuong Lam’s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate. The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards; that Section 17 leave is reviewed on a transfer (and especially to PICU); and to consider further the number of escorts required for any Section 17 leave. ”

    Source location

    Khuong Lam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Newcastle upon Tyne

    AI-generated summary

    Sheila Mary Hynes · 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 Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.

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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 involve and record discussions with the primary surgeon before remounting the valve

    Wider context from the report

    “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use. Concerns arising are: a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded. b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount. c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded. d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue. ”

    Source location

    Sheila Mary Hynes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Western)

    AI-generated summary

    Mr John Higgs · 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 John Higgs died at Barnsley General Hospital on 18 November 2015 from a ruptured abdominal aortic aneurysm. A CT scan in March 2011 had identified the aneurysm, but the finding was not communicated to Mr Higgs, other clinicians, or his general practitioner. The report raised concern that the Trust’s current system for communicating unexpected, significant non-cancerous radiological findings remained reliant on one doctor noticing and recording the information, with no red-flag facility or equivalent protocol.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings

    Wider context from the report

    “The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings. The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again. ”

    Source location

    Mr John Higgs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 Guidance and ICE electronic reporting systems are considered sufficient to significantly reduce the risk of similar radiological communication failures and future deaths.

    Verbatim wording from the response

    “████████ confirms the combination of the new Guidance, advice sought and the electronic reporting systems (ICE) now in place would significantly reduce the risk of a similar incident occurring in the future. The radiologist would be able to flag up a serious incidental finding to the treating clinician for their prompt action.”

    Source location

    John-higgs-Response
    Page 2 · response
    Published 17 May 2017

    Open published response

  5. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · 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

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Poor communication between clinicians and nurses

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. North Wales (Eastern and Central)

    AI-generated summary

    Mr Raymond Edwards · 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 Raymond Edwards underwent surgery for ischaemic bowel and later developed an anastomotic leak, sepsis and multi-organ failure; he died on 2 December 2015. The principal concern was the absence of a reliable system for ensuring that histology results reached the named consultant, in this case delaying awareness of amyloidosis.

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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 a reliable system for delivering histology results to named consultants

    Wider context from the report

    “During the Inquest it became clear that there is no reliable system or protocol for the dissemination of histology results to the named consultant for a patient. In this case the consultant for Mr Edwards informed the inquest that the histology result had gone to the file of Mr Edwards as he had been discharged. He did not chase the result as the operation passed without incident. The Consultant informed the court that had he had the result of histology showing amyloidosis that he would immediately have referred the patient on for urgent investigation of this serious condition. Having had these results at an early stage would have informed the treatment for Mr Edwards subsequently. The fact that this information was not passed in a timely fashion did not cause or contribute to the death of Mr Edwards. However, it is clear that unless there is a clear system for bringing histology results to the attention of a named Consultant that there could be a death in future. The consultant himself identified a need for a more robust system of delivering histology reports to consultants. ”

    Source location

    Mr Raymond Edwards · 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 Procedure MD23 to mitigate risks from failure to act on diagnostic results.

    Verbatim wording from the response

    “As a result of cases where failure to act on findings caused delays in patient treatment a series of meetings were arranged to review current practice and establish consistent and robust systems for disseminating results following examinations and tests. Work was undertaken to develop BCUHB Procedure MD23 ‘Procedure to mitigate the risks due to failure to act on diagnostic results’ based on NPSA 16 guidance. This procedure was approved at the end of 2016 and a copy is in the action plan.”

    Source location

    2017-0029-Response-by-University-Health-Board
    Page 1 · response
    Published 26 February 2017

    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 the CHAI Ping electronic reporting solution to alert requesting clinicians, record action taken, and reduce printing of WCP results.

    Verbatim wording from the response

    “To strengthen this process an electronic reporting system with a function to alert the requesting clinician when histology reports are authorised for viewing needs to be made available. Work has begun to develop the CHAI Ping app to provide the solution to the current gap in the WCP of ‘notification’ that a result is available and ‘authorise and recording of action taken’. This would work with the WCP to enable the organisation to improve assurance and stop printing reports for the results in scope i.e. those available to view in the WCP.”

    Source location

    2017-0029-Response-by-University-Health-Board
    Page 2 · response
    Published 26 February 2017

    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

    Following up and acting on histology results remains the ultimate responsibility of the health professional who ordered the investigation.

    Verbatim wording from the response

    “It is the ultimate responsibility of the health professional ordering the investigation to follow up the results and to act on them. This has been facilitated by the histology reports being sent to the requesting clinician and not the clinical location of the procedure. However paper histology reports may not reach their intended destination and for this reason all histology reports are also made available to the named Consultant on the Welsh Clinical Portal (WCP).”

    Source location

    2017-0029-Response-by-University-Health-Board
    Page 1 · response
    Published 26 February 2017

    Open published response

  7. South Yorkshire (Eastern)

    AI-generated summary

    Jane Bullock Wilson Stables · Prevention of Future Deaths report

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

    Report summary

    Jane Bullock Wilson Stables had severe rheumatoid arthritis, was bed bound and experienced poorly controlled pain and pressure sores. Concerns included ineffective communication between nurses and the general practitioner about her pain, and failure to follow the care plan for regular repositioning, with pressure sores significantly deteriorating before her admission to hospital, where she 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

    Ineffective communication about significant pain levels between nurses and the general practitioner

    Wider context from the report

    “(1) Ineffective communication between the nurses and general practitioner regarding ongoing significant pain levels which were impeding care provided. ”

    Source location

    Jane Bullock Wilson Stables · 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

    Convene a multidisciplinary meeting and produce a documented summary of learning and actions.

    Verbatim wording from the response

    “In relation to points one and two from my communication of 8 February, a meeting was held on 24 February 2017 between myself and the relevant District Nurses and their Line Managers. I chaired this meeting. I provided the attendees with a summary of my understanding of the case regarding Regulation 28 report. The participants were given the opportunity of reading this summary. They had already been sent a copy of your Regulation 28 report in advance.”

    Source location

    2016-0457-Response-by-RDASH
    Page 2 · response
    Published 12 February 2017

    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

    Consider direct professional dialogue about pain management when treatment is not optimised, regardless of patient or carer communication channels.

    Verbatim wording from the response

    “A full and frank discussion took place at this meeting. It was both professional and cordial. I produced the summary of the learning from that event with some actions. It included the need to consider a direct dialogue between professionals (including the GP) in relation to pain management if this was not optimised regardless of whether patients and/or carers maintained their own communication channels with pain management professionals.”

    Source location

    2016-0457-Response-by-RDASH
    Page 2 · response
    Published 12 February 2017

    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

    Operate a Lead Nurse referral system for branches to obtain clinical advice, contact GPs when necessary, and review patient documentation and care plans.

    Verbatim wording from the response

    “I can confirm that Allied Healthcare has, however, introduced a new system in which:-”

    Source location

    2016-0457-Response-by-Allied-Healthcare
    Page 2 · response
    Published 12 February 2017

    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

    When District Nurses were attending, they were responsible for escalating concerns to the GP, so carers were not required to contact the GP directly.

    Verbatim wording from the response

    “Allied Healthcare's attending carers were aware of, and were reporting to their local Allied Healthcare branch, Mrs Stables' ongoing pain/condition, utilising a standardised Early Warning Score assessment tool ("EWS"). However, it was, and still is, the responsibility of the attending District Nurses to escalate any concerns to the patient's GP (particularly when, as was the case here, they operate out of the patient's GP Practice). On that basis, it was not considered necessary for Allied Healthcare's staff to contact Mrs Stables' GP directly.”

    Source location

    2016-0457-Response-by-Allied-Healthcare
    Page 1 · response
    Published 12 February 2017

    Open published response

  8. Surrey

    AI-generated summary

    Matthew RUSSELL · 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

    Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

    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

    Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down

    Wider context from the report

    “g. Ensuring that there is regular effective communication about a patient’s needs with the GPs and the primary healthcare practitioners at HMP High Down. ”

    Source location

    Matthew RUSSELL · 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

    Review the Standard Operating Procedure for primary-care management of dual diagnosis and comorbidity, then submit it for ratification.

    Verbatim wording from the response

    “CNWL are currently reviewing our Standard Operating Procedure for working effectively with Primary care in managing dual diagnosis and co-morbidity via the Care Quality Management Meeting, and is due for review in February 2017 and ratification by the Clinical Director in April 2017.”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 4 · response
    Published 26 February 2017

    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

    Run weekly Mental Health team meetings with GP access, distribute agendas and minutes, and communicate urgent matters to GPs.

    Verbatim wording from the response

    “• Weekly Mental Health team meeting that includes standing open invitation to GPs. We do ensure that the agenda and minutes of the meeting are sent to the lead GPs. Urgent matters that arise in this meeting are communicated in a timely way to the GP’s if they are not present. Should the consultant psychiatrist not be present in the meeting then the responsible manager in that meeting contacts the Consultant Psychiatrist. Other or non-urgent matters are discussed at the Complex Case Review meeting (see point below).”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 9 · response
    Published 26 February 2017

    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 Consultant Psychiatrist Complex Case Review Meetings including relevant healthcare and custodial partners.

    Verbatim wording from the response

    “• Introduction of the CNWL Consultant Psychiatrist Complex Case Review Meetings at HMP Highdown to include GPs, Primary Care, Mental Health, Substance Misuse, Social Care, Safer Custody and Pharmacy that will commence in February 2017 to ensure that there is regular communication with all healthcare providers.”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 9 · response
    Published 26 February 2017

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · 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

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life 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 and document specialist treatment instructions

    Wider context from the report

    “16th May 2016 (1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made. (2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover. There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists. Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure communication between doctors and primary nurses after falls

    Wider context from the report

    “3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”

    Source location

    Margaret Emily TUCK · 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

    Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 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

    Hold four daily multidisciplinary safety handover meetings and use them to address communication between ward doctors, elderly-care and haematology teams.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    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