Recurring concern

Failure to conduct timely, appropriate clinical assessments

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First reported 28 Aug 2013•Latest report 17 Feb 2026

Definition

What this concern includes

Includes failures to conduct a clinically required assessment or full clinical review promptly and appropriately when the assessment is needed to identify or evaluate a patient's condition and guide safe care, including the anchor's delayed full review and delayed assessment of a patient's condition.

Not included

  • Excludes specialised assessment pathways with a distinct named subject or established safety concern, such as full mental-health assessments, VTE risk reviews or post-procedure complication assessments, unless the assertion also directly supports the same general clinical-assessment failure.
  • Excludes failures limited to the location, documentation, communication or handover of an assessment where the assessment itself was timely and appropriate.
  • Excludes delays in treatment, medication, escalation or referral when the required clinical assessment was completed appropriately and the remaining failure is downstream.
  • Excludes routine reassessment or review where no clinically required assessment or full clinical review is identified.
Reports
25

Distinct published reports

Individual concerns
28

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
38

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.

NHS England5
Care Quality Commission2
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bedford Prison1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Family of Julia Macpherson1
Glebelands1
Greater Manchester Health and Social Care Partnership1
HCRG Care Coventry LLP1
Marine Lake Medical Practice1
Ministry of Justice1
Monkstone House1

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. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 provide senior clinical review

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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

    Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    Open published response
  2. London (East)

    AI-generated summary

    Mr Pether · 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 Pether was admitted after a fall that caused a right femur peri-prosthetic fracture, with a pre-existing infection and an open fracture increasing the risk of infection. Transfer for complex surgery was delayed, and records identified no focused medical or nursing checks of limb viability between 11 and 20 December 2012. The wound was found to be infected and necrotic on 20 December; despite surgery, amputation and intensive care, Mr Pether deteriorated and died from left ventricular failure after developing multi-organ failure.

    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 conduct detailed assessment and re-consult treatment options during clinical deterioration

    Wider context from the report

    “3. By the 19 December 2012, there was a raised CRP and evidence of an acute kidney injury. It is certainly arguable that a more detailed assessment of the patient at that time and a re-consultation of options by the orthopaedic team should have taken place at that time. ”

    Source location

    Mr Pether · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester South

    AI-generated summary

    Frederick William Hall · 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

    Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.

    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

    Delays in seeking clinical review of deteriorating patients

    Wider context from the report

    “3. The monitoring of, and response to, the patient's condition seemed somewhat erratic. Both the surgeon and the senior nurse agreed that "an earlier review" should have been sought and that observations should have been taken more promptly following the patient having chest pains. ”

    Source location

    Frederick William Hall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. Cambridgeshire (South and West)

    AI-generated summary

    James Edward Mansfield · 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 Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

    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 arrange clinical assessment after a telephone report of pain in a high-risk patient

    Wider context from the report

    “(2) When ████████ telephoned the surgery, complaining of Mr Mansfield’s pain, strong pain killers were prescribed but he was not seen despite a long history of lung and chest complaints, multiple rib fractures and treatment with warfarin. ”

    Source location

    James Edward Mansfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Terrance O’Connell · 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

    Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.

    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 provide timely clinical assessment of a patient's condition

    Wider context from the report

    “(3) Mr O’Connell did not have any clinical assessment of his condition for 2 days until his admission to hospital ”

    Source location

    Terrance O’Connell · 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

    Implement a clinical-assessment policy requiring transfer to A&E when health professionals cannot attend within one hour.

    Verbatim wording from the response

    “Notwithstanding this, the Monkstone House policy has now been changed with regard to clinical assessment. The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 2 · response
    Published 28 August 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

    Hold senior-staff meetings to reinforce seeking medical advice and ensuring clients are seen by a professional when concerns arise.

    Verbatim wording from the response

    “3 Meetings have been held with senior staff and if there are any concerns regarding clients, staff are to seek medical advice, ensuring that all clients are seen by a professional. If, for whatever reason clients cannot be seen at Monkstone House and if out of hours GP and nurses will not attend, Monkstone House will send the client to A&E department for assessment as soon as practical.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 3 · response
    Published 28 August 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

    Develop a clear out-of-hours escalation process for resolving disputed clinical issues.

    Verbatim wording from the response

    “Issue identified: Lack of process in place to escalate the issue re the dispute between the two clinicians.”

    Source location

    2013-0218-Response-by-University-Health-Board
    Page 10 · response
    Published 28 August 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

    The district nursing assessment was appropriate because the catheter was draining freely; the patient required medical rather than nursing assessment.

    Verbatim wording from the response

    “The district nursing staff made an appropriate assessment on the information supplied by the care home i.e. that the catheter was draining freely, and therefore the cause of the pain would not have been a blocked catheter.”

    Source location

    2013-0218-Response-by-University-Health-Board
    Page 7 · response
    Published 28 August 2013

    Open published response
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Data last updated 7 September 2026