Recurring concern

Failure to reliably implement multidisciplinary team recommendations

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First reported 30 Dec 2015•Latest report 10 Feb 2023

Definition

What this concern includes

Includes failures within the dedicated multidisciplinary team recommendation process, including recording agreed actions, communicating outcomes to responsible clinicians, assigning responsibility, tracking follow-up and completing recommendations, including the anchor's uncompleted colorectal follow-up.

Not included

Excludes generic care-plan, communication, documentation or follow-up deficiencies unless they specifically concern recommendations or actions arising from a multidisciplinary team.
Excludes failures to convene or staff multidisciplinary meetings where no resulting recommendation or action implementation failure is identified.
Excludes clinical disagreements or decisions to depart from a recommendation where the departure is formally considered, documented and safely managed.
Excludes recommendations from individual clinicians or services unless they are explicitly part of a multidisciplinary team decision or recommendation.

Reports: 4
Individual concerns: 4
Date range: 2015–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Bolton NHS Foundation Trust1

Greater Manchester Mental Health NHS Foundation Trust1

NHS England1

NHS Greater Manchester Integrated Care Board1

Surrey and Sussex Healthcare NHS 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.

10 Feb2023
Manchester South
Concerns raised1
1. Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Sandra Adina Lomax · 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

Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
Wider context from the report
“4. This was compounded by the fact that the inquest heard evidence that the MDT did not have a system of effective communication of agreed actions and recommendations for individual patients discussed at the MDT. As a consequence local clinicians were unsighted as to the recommended way forward. The inquest was told that an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes. ”
Source location
Sandra Adina Lomax · 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
Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.

Verbatim wording from the response
“Recognising the challenges in relation to MDT working, the Greater Manchester Cancer Alliance have an improvement programme in place in relation to MDT reform:”

Source location
Response from Greater Manchester Integrated Care
Page 3 · response
Published 24 February 2023
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
Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.

Verbatim wording from the response
“GM are the appropriate organisation to respond to your concerns around GM staffing issues and ineffective communication between the MDT. I have been sighted on their response and welcome the Greater Manchester Cancer Alliance improvement programme for MDT reform. I also note that they will be sharing learning from Sandra’s death across the Greater Manchester System.”

Source location
Response from NHS England
Page 2 · response
Published 24 February 2023
Open published response
1 Apr2022
Manchester City
Concerns raised1
1. Failure to hold necessary MDT meetings and complete resulting actions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Name not published · 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

The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to hold necessary MDT meetings and complete resulting actions
Wider context from the report
“1. There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed. ”
Source location
Name not published · Prevention of Future Deaths report
Page 3 · concerns
Open source report
5 Nov2020
Surrey
Concerns raised1
1. Failure to action recommendations stemming from multidisciplinary team meetings
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Existing databases, tracking, cancer nurse specialist monitoring and escalation arrangements support appropriate follow-up of MDT recommendations.
  Stated by Surrey and Sussex Healthcare NHS TrustExisting arrangements considered sufficient
AI-generated summary

Linda Doherty · 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

Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on end-of-life care.

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 action recommendations stemming from multidisciplinary team meetings
Wider context from the report
“1. There was no colorectal follow up in relation to the findings of the CT scan carried out on 2 December 2016 despite it being recommended by the Upper Gastro-Intestinal Multi-Disciplinary Team meeting at East Surrey Hospital on 20 December 2016. Consideration should be given as to whether the appropriate procedures are in place to ensure that recommendations stemming from MDT meetings are actioned appropriately. ”
Source location
Linda Doherty · Prevention of Future Deaths report
Page 4 · 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
Existing databases, tracking, cancer nurse specialist monitoring and escalation arrangements support appropriate follow-up of MDT recommendations.

Verbatim wording from the response
“The current arrangements for the follow up of the recommendations made at the Upper GI MDT meeting were reviewed. The outcome for all patients discussed at the MDT meeting, whether cancer patients or not, are recorded on the Somerset database (a digital platform designed for healthcare professionals to manage cancer patient care). This is monitored by cancer services trackers who are then able to escalate to the most appropriate person any concerns i.e. tests not being requested and will chase dates as needed.”

Source location
2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
Page 8 · response
Published 21 December 2020
Open published response
30 Dec2015
Manchester West
Concerns raised1
1. Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review multidisciplinary team meetings and paperwork, and address poor documentation and failures to follow up meeting actions through a task-and-finish group.
  Stated by The TrustStated in progress
AI-generated summary

Mollie Bentham · 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

Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

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 attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes
Wider context from the report
“1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”
Source location
Mollie Bentham · 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 multidisciplinary team meetings and paperwork, and address poor documentation and failures to follow up meeting actions through a task-and-finish group.

Verbatim wording from the response
“A review of the conduct of MDT meetings including evaluation of the paperwork used at the meetings has been lead by Ann Lloyd, Consultant Nurse for Older People. ████████ has set up a task and finish group and taken steps to address the issues of poor documentation and failure to follow up actions identified at MDT meetings. I am advised this work is still ongoing however its purpose will be to ensure there is improved clinical decision making from all disciplines attending the MDT with appropriate timescales set for actions to be taken and completed, ultimately this will facilitate the safe discharge of our patients. It is expected that this work will be complete by 31 March 2016.”

Source location
Mollie-Bentham-Response
Page 2 · response
Published 30 December 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to hold necessary MDT meetings and complete resulting actions

Concerns raised1

Failure to action recommendations stemming from multidisciplinary team meetings

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 1

Respondent positions 1

Respondent positions 1

Actions described in response 1