Recurring concern

Unreliable access to relevant clinical records for safe care

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First reported 12 Sep 2013•Latest report 22 Jun 2026

Definition

What this concern includes

Includes failures to retrieve, locate, present or provide access to relevant existing records for assessment, treatment and care decisions.

Not included

  • Excludes absent or inaccurate information that was never reliably recorded.
  • Excludes failures to transfer otherwise available information to another service or recipient.
  • Excludes failure to review records that were already available unless access or retrieval was also deficient.
Reports
122

Distinct published reports

Individual concerns
129

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
192

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 Care23
NHS England22
Care Quality Commission6
Barts Health NHS Trust5
Betsi Cadwaladr University LHB5
HM Prison and Probation Service5
Cwm Taf Morgannwg University Local Health Board4
Manchester University NHS Foundation Trust4
Recipient name withheld4
Swansea Bay University Local Health Board4
Leicestershire Partnership NHS Trust3
North London NHS Foundation Trust3
Nottinghamshire Healthcare NHS Foundation Trust3
Royal London Hospital3
Tameside and Glossop Integrated Care NHS Foundation Trust3

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. Manchester South

    AI-generated summary

    Joseph James GRANTHAM · 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

    Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

    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 paper clinical notes to clinicians at appointments

    Wider context from the report

    “3. At ENT appointments and neurosurgery appointments at the RMCH, Joseph was seen without the paper notes because they had not been made available to the clinicians seeing Joseph. ”

    Source location

    Joseph James GRANTHAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Shropshire, Telford and Wrekin

    AI-generated summary

    Jerome Jason Omri JONES · 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

    Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.

    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 relevant prisoner medical information to drug workers

    Wider context from the report

    “(3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use. ”

    Source location

    Jerome Jason Omri JONES · 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

    Give every Forward Trust member access to SystmOne to enter and access information.

    Verbatim wording from the response

    “In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.”

    Source location

    2018-0369-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 10 May 2019

    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

    Medical information will not be shared without the patient's or representative's consent.

    Verbatim wording from the response

    “Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Heath, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent.”

    Source location

    2018-0369-Response-by-Shropshire-Community-Health-NHS-Trust
    Page 1 · response
    Published 10 May 2019

    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

    The Forward Trust's access to medical records is being addressed with NHS England, the service commissioner.

    Verbatim wording from the response

    “Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Heath, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent.”

    Source location

    2018-0369-Response-by-Shropshire-Community-Health-NHS-Trust
    Page 1 · response
    Published 10 May 2019

    Open published response
  3. Leicester City and South Leicestershire

    AI-generated summary

    John Charles Hazlewood · 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

    John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.

    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 remote access to medical records for on-call psychiatry clinicians

    Wider context from the report

    “1. The court heard that the on call Dr for psychiatry did not have remote access to Mr Hazlewood’s medical records and this prevented her from being informed of his significant psychiatric history, and furthermore prevented her from writing a note of her discussions regarding his request to self-discharge. Therefore the knowledge that he had presented again via ED with a serious overdose was not available to his Consultant so an opportunity was missed to escalate his care. Many of the on call team do have remote access and the Leicester Partnership Trust are asked to consider this issue for all relevant clinicians in order to avoid future difficulties of communication. ”

    Source location

    John Charles Hazlewood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide relevant psychiatry trainees and specialist trainees with remote access to all required clinical record systems.

    Verbatim wording from the response

    “████████, Clinical Director, has confirmed that all trainees on the relevant rota in Adult Mental Health and Learning Disabilities service now have remote access to the same clinical systems they would be able to access if they were working on the Trust’s sites. This means that all”

    Source location

    2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    Open published response
  4. Staffordshire South

    AI-generated summary

    Derek Reginald Smith · Prevention of Future Deaths report

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

    Report summary

    Derek Reginald Smith, who was bedbound and unable to manage his care needs, died at home on 21 December 2017 from aspiration pneumonia. He had developed a severe pressure sore, and the report raised concerns about limited communication between district nurses, family members and possibly carers, as well as the availability of nursing records and delays in treatment decisions.

    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

    Inadequate availability of nursing records

    Wider context from the report

    “It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well). There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved. ”

    Source location

    Derek Reginald Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Surrey

    AI-generated summary

    Henry James Heselton · 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

    Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

    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 make vital mental health history readily findable and extractable from electronic records

    Wider context from the report

    “1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis. ”

    Source location

    Henry James Heselton · 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 and redesign the RiO electronic patient record to make vital clinical information easier to find.

    Verbatim wording from the response

    “It has been recognised, by the Trust, that our electronic patient record, RiO, supports the recording and sharing of vital clinical information, including risk, more effectively than the previous paper record system, including improved legibility, organisation, sharing and identification of key information. However the system has faults and limitations, and information can be difficult to find. It is therefore subject to ongoing review so that it can be redesigned in a way which supports clinical practice. The clinical workforce receives training and support to be able to use the system effectively.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require staff to document risk information in the revised Risk Summary Section.

    Verbatim wording from the response

    “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement collaborative My Safety & Crisis Plans with regular completion and update prompts, including after significant risk changes.

    Verbatim wording from the response

    “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and use a Community Care Plan page to make care plans and risk summaries readily identifiable.

    Verbatim wording from the response

    “There has also been a review of the care planning process, and a Community Care Plan page developed (since January 2018), where all care plans are inserted so that they can be readily identified as well as the Risk summary.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response
  6. Milton Keynes

    AI-generated summary

    Philip David Ashton · 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

    Philip David Ashton, a resident of Mallard House, was administered warfarin in error on 13, 14 and 15 October 2017. He was found bleeding from an arteriovenous graft on 17 October, and the report raised concerns about the medication error, the lack of an emergency response and the unavailability of his medical information to ambulance staff; he later died in hospital.

    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 deceased's notes to ambulance staff

    Wider context from the report

    “(3) The ambulance staff were not given any information about the deceased as to his medical history or medication. The notes relating to the deceased should have been available to them. ”

    Source location

    Philip David Ashton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Cornwall and Isles of Scilly

    AI-generated summary

    David John Buttriss · 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 John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health 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 access to relevant records across healthcare providers

    Wider context from the report

    “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that • There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis • The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May. • It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision. ”

    Source location

    David John Buttriss · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.

    Verbatim wording from the response

    “We recognise that there are many challenges across the NHS to support secure data and record sharing, and we are actively leading a number of initiatives to address this. For example, the Global Digital Exemplar (“GDE”) programme, led”

    Source location

    2018-0010-Response-by-NHS-England
    Page 1 · response
    Published 7 March 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.

    Verbatim wording from the response

    “In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings. The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient’s history of contact with the NHS and related care services. This may include information from ‘physical health checks’ for people with serious mental illness which NHS England is encouraging a greater take up of. We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations – such as GP, Acute and Social Care settings – and across geographies as the patient moves.”

    Source location

    2018-0010-Response-by-NHS-England
    Page 2 · response
    Published 7 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing secure RiO access arrangements are considered sufficient for sharing health records with other agencies.

    Verbatim wording from the response

    “The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs.”

    Source location

    2018-0010-Response-by-Cornwall-NHS-Trust
    Page 2 · response
    Published 7 March 2018

    Open published response
  8. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Donald John TILL · 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

    Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.

    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 previous medical records for clinical decision-making

    Wider context from the report

    “1. The deceased’s previous medical records were not available. Different clinical decisions might have been made had they been available. ”

    Source location

    Donald John TILL · 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

    Establish a fully electronic case-notes system to improve access to medical records.

    Verbatim wording from the response

    “1. The Trust is in the process of establishing a fully electronic case notes system, however, this is a planned programme over a number of years due to the scale and complexity of the requirements which also requires funding. Nevertheless, there are currently well established processes in place to access medical records for urgent admissions. All staff have access to the Trust ‘file-fast case-note tracking system’ to identify the location of the medical records and are able to request retrieval of the records thereafter. Some medical records are stored off site due to the practical difficulties of storing vast amounts of paper-based records.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 2 · response
    Published 7 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Established tracking, retrieval and out-of-hours arrangements are considered sufficient for accessing medical records during urgent admissions.

    Verbatim wording from the response

    “1. The Trust is in the process of establishing a fully electronic case notes system, however, this is a planned programme over a number of years due to the scale and complexity of the requirements which also requires funding. Nevertheless, there are currently well established processes in place to access medical records for urgent admissions. All staff have access to the Trust ‘file-fast case-note tracking system’ to identify the location of the medical records and are able to request retrieval of the records thereafter. Some medical records are stored off site due to the practical difficulties of storing vast amounts of paper-based records.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 2 · response
    Published 7 March 2018

    Open published response
  9. Isle of Wight

    AI-generated summary

    Joseph Peter Dunne · 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

    Joseph Peter Dunne, aged 58, was discharged from hospital on 14 July 2015 after presenting with pain and feeling unwell, and was later found collapsed at home on 16 July 2015. He became unresponsive while using the toilet and was pronounced dead at 3.20 p.m.; the medical cause of death was peritonitis due to a perforated duodenal ulcer. The report raises concerns about Information Governance breaches that allowed clinical records, including an abnormal D-dimer result, to be deleted or altered and not seen by treating clinicians.

    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 make medical-record edits visible to treating clinicians

    Wider context from the report

    “1. I am concerned that there are clear breaches in Information Governance protocols. It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database, or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal). Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient, and are only ascertainable when an IT audit trail is undertaken. It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records. ”

    Source location

    Joseph Peter Dunne · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  10. Manchester South

    AI-generated summary

    Lindsey Theresa Hassall · 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

    Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.

    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 make documentation accessible to all relevant staff

    Wider context from the report

    “• The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known to workers dealing with her. ”

    Source location

    Lindsey Theresa Hassall · 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

    Develop and display a laminated flowchart guiding s136 handover recording, documentation access and referral processes.

    Verbatim wording from the response

    “▪ Flowchart to be developed which reflects guidance in staff briefing – laminated copy to be displayed in 136 suite so it is available to staff coordinating and undertaking s136 assessments.”

    Source location

    2017-0429-Responses
    Page 1 · response
    Published 27 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide staff guidance on accessing notes in and out of hours, including support from colleagues and s136-suite staff when required.

    Verbatim wording from the response

    “As part of the above plan the following actions are in place:”

    Source location

    2017-0429-Responses
    Page 2 · response
    Published 27 February 2018

    Open published response
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Data last updated 7 September 2026