Recurring concern

Failure to consider or reconsider serious alternative diagnoses

First to latest report 23 Sep 2013 — 9 May 2025

Reports that mention this concern
17
Times this concern has been raised
18
Stated actions linked to this concern
29

What this concern includes

Includes failure to consider life-threatening or organic alternatives during initial assessment and failure to revisit a diagnosis when symptoms, investigations or treatment response are inconsistent.

What is not included
  • Diagnostic-test availability where differential diagnosis was appropriate
  • Failure to act on a confirmed result where diagnostic reconsideration is not deficient
  • Condition-specific pathways that provide a narrower supported recurring concern

Reports and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South Wales Central

    AI-generated summary

    Mr. Christopher Summerhayes · 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. Christopher Summerhayes was found deceased at his home address after a significant medical history including double scoliosis, treatment-resistant schizophrenia and a complex regime of around 12 daily medications. The concerns included the prescription of clozapine alongside other medications, substantial weight gain and possible effects on his cardiovascular system, as well as a possible familial lipid disorder. The inquest concluded that the medical cause of death was ischaemic heart disease, with a narrative determination referring to atypical early-onset coronary artery atherosclerosis and complex prescribed medications.

    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 distinguish clozapine overdose signs from unresolved schizophrenia symptoms

    Wider context from the report

    “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing. (2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine. ”

    Source location

    Mr. Christopher Summerhayes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · 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

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    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 review an initial diagnosis when the patient deteriorates

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    David Michael little · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to assess differential diagnoses from the most serious potential condition

    Wider context from the report

    “3. Where there is a differential diagnosis of two or more potential conditions, the staff simply treated the least serious and assumed that was the correct diagnosis rather than taking the most serious and working backwards from that standpoint. ”

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish and ratify a small bowel obstruction surgical pathway covering diagnostic priorities and monitoring for this patient group.

    Verbatim wording from the response

    “The Trust has devised a small bowel obstruction surgical pathway (Document 3 attached) which now describes the pathway and monitoring plan for this patient group. Learning undertaken following Mr Little’s death has been incorporated into this pathway. It has been agreed by the surgical, nursing and clinical teams and will be ratified as described in the document, through the governance forums in General Surgery, Radiology, Urgent Care & Critical Care before being signed off at Trust level by the end of September.”

    Source location

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

    Open published response

  4. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 consider surgical causes of abdominal symptoms after bariatric surgery

    Wider context from the report

    “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery. I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery. ”

    Source location

    Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Worcestershire

    AI-generated summary

    James Paul COLTON · 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

    James Paul COLTON was a serving prisoner who became critically unwell on 29 August 2013 after a period of deteriorating health and died two days later in hospital. Concerns included failure to revisit his diagnosis or escalate treatment, inadequate analgesia, poor continuity and communication of care, and an extremely heavy workload affecting healthcare provision.

    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 reassess diagnoses and escalate treatment despite continuing clinical decline

    Wider context from the report

    “(1) The doctors and nurses at the prison failed to properly diagnose, treat and care for Mr Colton in that they assumed that the diagnosis of mechanical back pain was accurate and took no steps to revisit the diagnosis or to escalate his treatment despite his obvious continuing decline. The failure to consider alternate diagnosis led to him missing his developing cancer and which may, therefore, have contributed to his early death. ”

    Source location

    James Paul COLTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.

    Verbatim wording from the response

    “Importantly, a couple of study sessions were held in which staff were taken through the case notes of Mr Colton and had an opportunity to discuss learning identified and how they may act in future situations. Whilst there are a number of learning objectives for the day, principally, staff were asked to be open and to be curious in clinical situations. I understand from my Deputy Head of Healthcare at HMP Long Lartin that staff still talk about the learning generated from this case and in the last week there has been an example of staff raising an issue and being encouraged to consider alternative options.”

    Source location

    2015-0021-Response-by-Worcestershire-Health-Care-NHS
    Page 1 · response
    Published 21 January 2015

    Open published response

  6. Surrey

    AI-generated summary

    Clare Serena Anke 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

    Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

    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 documented list of potential diagnoses for exclusion at eating-disorder triage

    Wider context from the report

    “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service. ”

    Source location

    Clare Serena Anke COOPER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 robustly assess presenting signs and symptoms and consider or exclude organic causes

    Wider context from the report

    “2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause. ”

    Source location

    Clare Serena Anke COOPER · 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

    Revise the eating-disorder triage form to record investigations, physical findings, symptoms, medical history, and potential organic causes.

    Verbatim wording from the response

    “We have however reviewed our triage form to ensure that all information including physical investigations is recorded in one form. The changes made include:”

    Source location

    2014-0345-Response-by-Surrey-Borders-Partnership-NHS
    Page 2 · response
    Published 25 July 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

    Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.

    Verbatim wording from the response

    “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.”

    Source location

    2014-0345-Response-by-Surrey-Borders-Partnership-NHS
    Page 1 · response
    Published 25 July 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

    Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.

    Verbatim wording from the response

    “We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant.”

    Source location

    2014-0345-Response-by-Woodlands-Surgery
    Page 2 · response
    Published 25 July 2014

    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

    Advice on concerns relating to hospital medicine should be obtained from hospital medicine rather than the College.

    Verbatim wording from the response

    “I give below detailed comments on the first six matters of concern you list in this particular case, ie those which directly relate to general practitioner care, setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate.”

    Source location

    2014-0345-Response-by-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 25 July 2014

    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

    GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.

    Verbatim wording from the response

    “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.”

    Source location

    2014-0345-Response-by-Surrey-Borders-Partnership-NHS
    Page 1 · response
    Published 25 July 2014

    Open published response

  7. London North (Inner)

    AI-generated summary

    Michael James SWEENEY · 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

    Michael James Sweeney died after taking cocaine and becoming extremely agitated; he was transported to hospital by police after an ambulance was not sent within the target time. He was restrained prone until sedation was effective, then arrested and died less than two hours later. The principal concerns were the inconsistent use and understanding of the term “excited delirium”, the risk of missing other medical causes of extreme agitation, and ambulance-service prioritisation of such emergencies.

    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

    Reliance on “excited delirium” as an apparent diagnosis risking missed organic causes

    Wider context from the report

    “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country, and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011. It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round. Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis. Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma. From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause. 1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”. 2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now. 3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service. 4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately. ”

    Source location

    Michael James SWEENEY · 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

    Adopt Acute Behavioural Disorder as the common terminology for the relevant medical emergency.

    Verbatim wording from the response

    “Secondly, both national and Metropolitan Police training on the correct terminology to use have in fact already moved on since the date of this incident. Though the ‘constellation of behaviours’ has at various points in the developing knowledge about it’s causes and effects been known (inter alia) as ‘cocaine psychosis’, and ‘excited delirium’, since 2010 the generally recognised phrase within UK police texts has been ‘Acute Behavioural Disorder’ (‘ABD’). This phrase was chosen to provide exactly the “ ‘precision without ‘diagnosis’ “ you indicated would be a necessary element of any common terminology adopted. Inspector ████████ provides the practitioner’s context:”

    Source location

    2013-0236-Response-by-Metropolitan-Police
    Page 3 · response
    Published 23 September 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

    Maintain Acute Behavioural Disorder content in officers’ regular Officer Safety and Emergency Life Support training, including refresher training.

    Verbatim wording from the response

    “The generic term Acute Behaviour Disorder was selected as the most appropriate term and ABD was subsequently fast-tracked into the National Personal Safety Manual. The Faculty of Forensic and Legal Medicine also adopted the terminology of ABD, and have produced guidance on the management of this condition. The medical implications of the manual's techniques and guidance (including ABD) were reviewed by Professor ████████ in 2010. Furthermore, additional improvements were most recently made to the ABD advice by Professor ████████ in 2012, following Rule 43 advice in another case.”

    Source location

    2013-0236-Response-by-Metropolitan-Police
    Page 3 · response
    Published 23 September 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

    Encourage NHS partners to adopt Acute Behavioural Disorder terminology and increase supporting awareness of the condition.

    Verbatim wording from the response

    “The potential information gap for MPS civil staff working at Central Communications Command who do not receive this training routinely has been addressed by the issuing of direct practice notes, and supported by a programme of in-house training on awareness of the issues and correct procedures to adopt. Meanwhile, the development of a detailed and documented joint agency call-handling protocol with our partners at London Ambulance Service, contained within the new Memorandum of Understanding, gives both ‘First Responder’ agencies a common wellspring of guidance to draw upon, a robust channel of communication where ABD is suspected, and clarity regarding the expectations each agency can have of the other’s response in these circumstances. It is now important that staff in emergency departments are also made aware of this condition and its management.”

    Source location

    2013-0236-Response-by-Metropolitan-Police
    Page 5 · response
    Published 23 September 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

    Raise terminology and guidance issues through the national Ambulance Service Mental Health Working Group for review.

    Verbatim wording from the response

    “excited delirium, which specifically relates to police incapacitant devices (TASERS). We have raised this issue through the national Ambulance Service Mental Health Working Group, asking them to look both at the appropriate terminology and guidance around the subject matter itself. The national Ambulance Service Mental Health Working Group has confirmed that they will issue a position statement about the use of an appropriate term following a response to their proposal from the Royal College of Psychiatrists.”

    Source location

    2013-0236-Response-by-London-Ambulance-Service
    Page 3 · response
    Published 23 September 2013

    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

    “Extreme agitation” is rejected because its broad meaning could obscure the specific constellation of behaviours indicating a medical emergency.

    Verbatim wording from the response

    “However, the use of the particular phrase ‘extreme agitation’ in place of ‘extreme delirium’ was universally rejected, by both the local partner agencies approached by ████████ through the Clinical Panel, and by the setters of national police policy through the Association of Chief Police Officers, as reported by Inspector ████████ The reasons for this were as follows:”

    Source location

    2013-0236-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 September 2013

    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 Acute Behavioural Disorder training makes additional police training changes on terminology and recognising the medical emergency unnecessary.

    Verbatim wording from the response

    “Your recommendation regarding a common terminology has been accepted by all partners. It is respectfully submitted however that the adoption by the London Ambulance Service of the term ‘Acute Behavioural Disorder’ as the term of choice effectively negates the additional training changes recommended in points 1 and 2 of your report, as active training on ABD and responses to it remain an ongoing element in all regular refresher training sessions for police officers, and this, we are given to understand, is now being paralleled within the LAS via their own training and practice direction regimes.”

    Source location

    2013-0236-Response-by-Metropolitan-Police
    Page 5 · response
    Published 23 September 2013

    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