Recurring concern

Unreliable recording and preservation of safety-relevant telephone calls

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First reported 20 Apr 2017•Latest report 22 Jul 2024

Definition

What this concern includes

Includes failures of controls dedicated to recording, preserving, securely storing, retrieving or making available safety-relevant telephone calls, including calls involving detainees, patients or crisis services, where missing or inaccessible recordings can impair care, investigation or accountability.

Not included

  • Excludes generic documentation or records-management deficiencies that are not specifically tied to recording or preserving safety-relevant telephone calls.
  • Excludes non-telephone audio, video, radio or CCTV recordings unless the report explicitly links them to the same telephone-call recording process.
  • Excludes failures limited to reviewing, interpreting or acting on a recording that was reliably preserved and available.
  • Excludes routine telephone calls with no identified safety, care, risk-management or investigative relevance.
Reports
8

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2017–2024

First to latest report issue date

Stated actions
4

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 Care2
NHS England2
Care Quality Commission1
Carillion (AMBS) Limited1
College of Policing1
East Kent Hospitals University NHS Foundation Trust1
General Medical Council1
HM Prison and Probation Service1
Home Office1
National Police Chiefs’ Council1
Norfolk and Suffolk NHS Foundation Trust1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Rush Green Medical Centre1
Tees, Esk and Wear Valleys NHS Foundation 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. Suffolk

    AI-generated summary

    Gemima CHRISTODOULOU-PEACE · 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

    Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before her death.

    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

    Limited recording of telephone interactions with patients

    Wider context from the report

    “2. There are currently only a limited number of calls going into the Norfolk and Suffolk Foundation Trust which are being recorded. As such, should the clinician taking the call suddenly need to be absent (e.g. sudden ill health, domestic emergency, etc) and therefore cannot provide details of the call, there is no way any other treating clinician can respond to needs of that patient, or address any risks to that patient identified in that call. In addition, without a recording of calls there is no opportunity to review cases were there may be some doubt as to what a patient or clinician has said, or when a different clinician wishes to hear the patient themselves to independently assess the patients presentation, or for a Multi-Disciplinary Team to review the contents of that call. As many interactions between the NSFT and patients are telephone based, the availability of accurate recording of those conversations, and increased accessibility to them, would improve patient safety. ”

    Source location

    Gemima CHRISTODOULOU-PEACE · Prevention of Future Deaths report
    Page 2 · 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 provide accessible telephone call recordings for clinical review

    Wider context from the report

    “2. There are currently only a limited number of calls going into the Norfolk and Suffolk Foundation Trust which are being recorded. As such, should the clinician taking the call suddenly need to be absent (e.g. sudden ill health, domestic emergency, etc) and therefore cannot provide details of the call, there is no way any other treating clinician can respond to needs of that patient, or address any risks to that patient identified in that call. In addition, without a recording of calls there is no opportunity to review cases were there may be some doubt as to what a patient or clinician has said, or when a different clinician wishes to hear the patient themselves to independently assess the patients presentation, or for a Multi-Disciplinary Team to review the contents of that call. As many interactions between the NSFT and patients are telephone based, the availability of accurate recording of those conversations, and increased accessibility to them, would improve patient safety. ”

    Source location

    Gemima CHRISTODOULOU-PEACE · Prevention of Future Deaths report
    Page 2 · 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

    Recording all clinical calls is considered disproportionate; recording remains limited to NHS 111 and designated crisis-team lines.

    Verbatim wording from the response

    “Turning to your concerns around the recording of incoming phone calls made to the Norfolk and Suffolk NHS Foundation Trust, I can appreciate the potential risks this may pose, as you have highlighted. The Trust has advised that it has recently considered the issue of recording clinical calls and taken the decision that it would be proportionate to extend clinical call recording from NHS 111 (option 2) only to within crisis teams within the organisation and all phone lines which have been designated as requiring recording facility have now been enabled.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 31 July 2024

    Open published response
  2. Suffolk

    AI-generated summary

    Ellen Ocean WOOLNOUGH · 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

    Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

    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 retain recordings of calls for serious patient incident investigations

    Wider context from the report

    “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust. ”

    Source location

    Ellen Ocean WOOLNOUGH · 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 preserve recordings of calls between patients and the crisis call handler

    Wider context from the report

    “v. The failure by NSFT to preserve important evidence, in the form of recordings of calls between Ellie and the NSFT crisis call handler, at a time when it was not on notice that this evidence would be important and relevant for the conduct of the Inquest, remains a concern. ”

    Source location

    Ellen Ocean WOOLNOUGH · 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 patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.

    Verbatim wording from the response

    “4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 15 April 2024

    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

    Establish consistent, information-governance-compliant retrieval of relevant patient-call recordings by the Patient Safety team.

    Verbatim wording from the response

    “this screening form, to prompt the clinical team that are providing an initial description of the events that have occurred, to consider whether any patient calls are available for retrieval, so that they can be secured for investigation and inquest purposes. We have strong processes in place to ensure that the retrieval of these calls is undertaken in a consistent and IG compliant manner by members of the Patient Safety team.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 3 · response
    Published 15 April 2024

    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 call-recording capability across designated crisis-pathway phone lines, including the identified CRHTT area.

    Verbatim wording from the response

    “Recognising that we have an extensive network of phone lines, we have also taken steps to secure assurance that the phone lines that we need recording, across the crisis pathways, are appropriately enabled. Through a detailed scoping exercise, we identified the need to extend our current recording facility in one of our CRHTT areas. This went live on 15th May 2024. All phone lines which have been designated as requiring recording facility have now been enabled.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 3 · response
    Published 15 April 2024

    Open published response
  3. Manchester South

    AI-generated summary

    Donna Constantine · 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

    Donna Ann Constantine, a vulnerable adult known to multiple agencies, was found severely decomposed at her home on 21 September 2019 after neighbours raised concerns. The post-mortem examination could not establish a cause of death, and the inquest conclusion was open. Concerns included the use of unmonitored police work mobile phones for contact from vulnerable people, alongside the absence of clear escalation, audit-trail, and verbatim call-recording policies.

    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 verbatim recording for calls received by officers

    Wider context from the report

    “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. ”

    Source location

    Donna Constantine · Prevention of Future Deaths report
    Page 2 · 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

    Specific policing issues are for Greater Manchester Police, the National Police Chiefs’ Council and the College of Policing to address.

    Verbatim wording from the response

    “I acknowledge your concerns detailed in your report, and should stress that police forces are operationally independent and, as such, it is for the Greater Manchester Police, the National Police Chiefs Council and the College of Policing to address the specific issues raised about their ways of working as they relate to the inquest into the death of Ms Constantine. However, I can reassure you that the NPCC and CoP, who you have named in the report and have operational responsibilities, are aware of the recommendations and are working together to address them and respond within the requisite 56-day period.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 21 October 2021

    Open published response
  4. East London

    AI-generated summary

    Theresa Robertson · 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

    Theresa Robertson was found deceased outside 90 Greengate Street on the evening of 18 September 2019, after being captured on CCTV in the area two days earlier. The medical cause of death was recorded as Amitriptyline and Zopiclone toxicity and hypothermia. Concerns included missing records of important telephone calls and a consultation, prescriptions exceeding the surgery’s seven-day limit for high-risk patients, and the absence of assurance that other patients’ prescriptions had been audited.

    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 document critically important telephone calls regarding patients

    Wider context from the report

    “1. The surgery admitted that no documentary record was taken of two critically important telephone calls between ████████ and the surgery regarding the deceased. ”

    Source location

    Theresa Robertson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. North East Kent

    AI-generated summary

    HARRY RICHFORD · 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

    Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

    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 record consultant telephone advice

    Wider context from the report

    “Concern 14 There are no current records kept by consultants who are telephoned at home for advice. In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life. ”

    Source location

    HARRY RICHFORD · Prevention of Future Deaths report
    Page 17 · 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

    The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

    Verbatim wording from the response

    “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 October 2022

    Open published response
  6. Central Hampshire

    AI-generated summary

    Sean Patrick Plumstead · 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

    Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.

    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 storage of telephone recordings

    Wider context from the report

    “(1) Winchester Prison has been unable to produce the telephone recordings and the transcripts provided are in summary form only and so may omit potential evidence. The systems in place for proper storage of such material appear to be inadequate or non-existent. ”

    Source location

    Sean Patrick Plumstead · 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

    Review accounting systems and storage of internal investigation material to identify and rectify weaknesses.

    Verbatim wording from the response

    “As a result of this, the Head of Business Assurance at the prison is carrying out a review of accounting systems and storage of internal investigation material at HMP Winchester with a view to identifying and rectifying areas of weakness.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services
    Page 2 · response
    Published 3 December 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

    HMP Winchester had recordings of all telephone calls, although access was restricted because the listening system was encrypted.

    Verbatim wording from the response

    “1) HMP Winchester does have recordings of all telephone calls made by Mr Plumstead and will provide you with a copy as directed. HMP Winchester have always had copies of the calls but the system on which calls are accessed to be listened to is encrypted.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services
    Page 1 · response
    Published 3 December 2017

    Open published response
  7. Manchester West

    AI-generated summary

    Patricia Forshaw · 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

    Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for 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 record telephone calls and advice concerning discharged patients

    Wider context from the report

    “ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20th October 2016 and the advice to give paracetamol was not recorded in any Hospital records. Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased. The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor. ████████ commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw. ”

    Source location

    Patricia Forshaw · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  8. County Durham and Darlington

    AI-generated summary

    Thomas Whitfield · 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

    Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.

    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 monitoring or recording of telephone calls

    Wider context from the report

    “The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns. Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen. ”

    Source location

    Thomas Whitfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026