Recurring concern

Failure to assure clinical information communication processes

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First reported 8 Nov 2013•Latest report 29 Mar 2017

Definition

What this concern includes

Includes dedicated checking, auditing, monitoring or assurance controls for clinical information communication processes between staff, teams or services, including assurance that information and clinical decisions are received accurately, promptly and completely and that the communication process operates consistently in practice.

Not included

  • Excludes generic clinical communication failures where the communication process itself is deficient but no checking, auditing or assurance failure is identified.
  • Excludes generic organisational audits, records audits and governance reviews that do not specifically assure a clinical information communication process.
  • Excludes non-clinical communication systems and communication processes whose subject is not patient-care information or clinical decisions.
  • Excludes failures to act on information after a communication process has been reliably assured, unless the assurance process itself is also deficient.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2017

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Cygnet Health Care Limited1
Dinnington Group Practice1
Recipient name withheld1
Yorkshire Ambulance Service NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Eastern)

    AI-generated summary

    Lyndsey Holt · 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

    Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.

    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

    Absence of systems to audit the effectiveness and reliability of the pre-alert system

    Wider context from the report

    “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows: (1) Absence of systems to audit the effectiveness and reliability of the pre-alert system. (2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests, the importance of doing and conveyance of all relevant clinical information. ”

    Source location

    Lyndsey Holt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire (West)

    AI-generated summary

    Peter Patrick Adrian Barnes · Prevention of Future Deaths report

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

    Report summary

    Peter Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.

    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

    Absence of checking and auditing of clinical information communication systems

    Wider context from the report

    “(3) There appeared to be no system of checking upon or auditing the systems referred to at paragraphs (1) and (2) above to ensure that the Responsible Clinician was receiving full, accurate and up to date information and that nursing staff were receiving appropriate and timely information about the Responsible Clinician’s decisions. ”

    Source location

    Peter Patrick Adrian Barnes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026