Recurring concern

Failure of case monitoring to identify cases requiring follow-up

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First reported 27 Dec 2013•Latest report 4 Mar 2026

Definition

What this concern includes

Includes failures of case monitoring, allocation tracking or referral follow-up where the control does not identify that a case has not been seen, assessed or progressed.

Not included

  • Excludes failures limited to the quality of clinical documentation when they do not concern identifying cases requiring follow-up.
  • Excludes delays or missed actions where no monitoring, tracking or follow-up identification failure is described.
  • Excludes generic staffing, communication or technology deficiencies not explicitly tied to monitoring or follow-up of cases.
Reports
33

Distinct published reports

Individual concerns
36

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
49

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.

Department of Health and Social Care6
Care Quality Commission5
NHS England3
Egton Medical Information Systems Limited2
NHS Greater Manchester Integrated Care Board2
Asthma + Lung UK1
Avenue House Nursing and Care Home1
Bexley Medical Group1
Bow School1
Brighton and Hove City Council1
Bristol NHS Foundation Trust1
British Society Of Gastroenterology1
Bromley by Bow Health Centre1
Chelsea and Westminster Hospital1
City Health Care Partnership CIC1

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. Inner South London

    AI-generated summary

    Yaser Saleh · 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

    Yaser Saleh, aged 15, died on 13 September 2012 after collapsing with cardio-respiratory arrest from acute asthma. The report raised concerns that electronic systems did not identify asthma patients needing review when they were no longer receiving regular prescriptions, creating a risk of preventable deaths in people with chronic diseases.

    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 computerised recall systems to identify chronic disease patients requiring review beyond current prescribing

    Wider context from the report

    “The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review. Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication. She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report. The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy. This risk of not identifying those at risk of death because they no longer comply or have not been prescribed treatment taken in the past brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring, are triggered for the attention of the GP, on wider criteria than current prescribing, or if such a system is available that the Department considers using it and other GPs are made aware of its use. ”

    Source location

    Yaser Saleh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Leslie Edmund Harding (Lez) · 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 Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events 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 check for omissions in anticoagulation treatment for other patients

    Wider context from the report

    “2. Your practice will have a number of other patients in receipt of anti-coagulation treatment following recurrent Pulmonary Embolii. Given the omission that appears to have occurred here, you need to ensure that no other omissions have happened with any of the other patients ”

    Source location

    Leslie Edmund Harding (Lez) · 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

    Audit all patients receiving acute or recurrent pulmonary-embolism treatment for similar omissions.

    Verbatim wording from the response

    “2) Having reviewed this case, I am undertaking an audit of all people receiving treatment for pulmonary emboli whether acute or recurrent to ensure that no similar omissions have occurred.”

    Source location

    2014-0169-Response-by-Oakside-Surgery
    Page 2 · response
    Published 8 April 2014

    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

    Extend the anticoagulation review to patients receiving low-molecular-weight heparin and novel oral anticoagulants.

    Verbatim wording from the response

    “We have also decided to extend this review to patients receiving low molecular rate heparin and novel oral anti-coagulants.”

    Source location

    2014-0169-Response-by-Oakside-Surgery
    Page 2 · response
    Published 8 April 2014

    Open published response

  3. Manchester West

    AI-generated summary

    Howard Simon Sankey · 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

    Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff training.

    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

    Unavailability of the computerised referral list to Senior Nurse Practitioners

    Wider context from the report

    “(1) During the Inquest evidence was heard that :- i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt. ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user. iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team. iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day. Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day. v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013. vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral. 2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to: i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral. iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed. iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners. v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed. vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day. vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period. viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods. ”

    Source location

    Howard Simon Sankey · 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

    Require the senior nurse practitioner on duty to clinically review unprioritised referrals and assign a priority within 30 minutes.

    Verbatim wording from the response

    “I. It is the referrer and not an administrator who categorises referrals. A system is in place whereby administration staff place referrals in an appropriate tray based on the referral priority provided by the referrer, who is usually a general practitioner. Where no priority has been identified by the referrer this is now brought to the immediate attention of the senior nurse practitioner on duty who will review the referral and assign the appropriate clinical priority within a maximum of 30 minutes of receipt.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 2 · response
    Published 27 December 2013

    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 uncontacted routine referrals in the next-day multidisciplinary meeting and record decisions and formal shift handovers in the electronic information system.

    Verbatim wording from the response

    “In the case of referrals considered to be of a routine nature, they are discussed the next day in the morning meeting and a decision taken as to whether the cases need to be reprioritised. A multi-disciplinary team decision is taken on the next action required, which can include an increase in referral priority or further discussions with the referrer on the appropriate course of action.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 2 · response
    Published 27 December 2013

    Open published response
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Data last updated 7 September 2026