Recurring concern

Unreliable circulation of safety-critical mental health information

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First reported 25 Jun 2014•Latest report 8 Apr 2026

Definition

What this concern includes

Includes failures in dedicated processes for circulating, receiving, reading or making available safety-critical mental health information to staff responsible for assessment, triage, response or ongoing care, including ambulance-control communications, mental-health-team messages and internal team communications.

Not included

Excludes generic communication, staffing, documentation or information-system deficiencies where safety-critical mental health information is not the material object of the failure.
Excludes failures in clinical assessment, treatment or escalation after the relevant mental health information was reliably received and available.
Excludes routine administrative or non-safety-related mental health communications.
Excludes failures confined to a separately named mental health referral, crisis, appointment or information system when that named process supplies the more specific supported boundary.

Reports: 14
Individual concerns: 17
Date range: 2014–2026
Stated actions: 35

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.

Essex Partnership University NHS Foundation Trust2

Metropolitan Police Service2

Achieve Together Limited1

Betsi Cadwaladr University LHB1

Cheshire and Wirral Partnership NHS Foundation Trust1

College of Policing1

Department of Health and Social Care1

East London NHS Foundation Trust1

Essex County Council1

Greater Manchester Mental Health NHS Foundation Trust1

Greater Manchester Police1

Home Office1

Manchester University NHS Foundation Trust1

Ministry of Justice1

Nestor Primecare Services Limited1

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.

28 Jul2016
Manchester City
Concerns raised1
1. Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission
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
  Implement a Trustwide policy or pathway for proactively gathering complex and vulnerable patients’ up-to-date information from external health providers.
  Stated by Manchester University NHS Foundation TrustStated planned
AI-generated summary

Leslie Johnson · 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

Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the 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
Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission
Wider context from the report
“3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital, but nor did the hospital check or request information from those looking after him in the community. The concern is that in this case, the deceased’s death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital. ”
Source location
Leslie Johnson · Prevention of Future Deaths report
Page 4 · 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 Trustwide policy or pathway for proactively gathering complex and vulnerable patients’ up-to-date information from external health providers.

Verbatim wording from the response
“Currently as a Trust we do not have a formal policy in place for the sharing of up to date information for patients who are vulnerable or have complex conditions. Whilst staff will informally liaise with care agencies or primary care, this is ad hoc and not an embedded process therefore relies on the staff providing care to a patient to proactively consider the information that may be held elsewhere. There are exceptions to this however, such as patients with learning disabilities, where there is a formal process in place through the use of their LD passport; however this is not consistent across other patient groups. As a result of the findings of this case we will implement a Trustwide initiative regarding the development of a policy or pathway for complex and vulnerable patients which will include proactively gathering information from health providers outside of the Trust.”

Source location
MORRISON-Leslie-Response
Page 2 · response
Published 28 July 2016
Open published response
12 Jun2015
North Wales (East and Central)
Concerns raised1
1. Failure to provide access to mental health information during medical treatment
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 2
1. Action
  Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.
  Stated by Betsi Cadwaladr University LHBStated in progress
AI-generated summary

Nancy Hughes · 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

Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.

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 access to mental health information during medical treatment
Wider context from the report
“2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support. ”
Source location
Nancy Hughes · 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
Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.

Verbatim wording from the response
“This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have a named individual who coordinates their care, ie their Care Coordinator.”

Source location
2015-0221-Response-by-University-Health-Board
Page 1 · response
Published 12 June 2015
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
Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.

Verbatim wording from the response
“The role of the Care coordinator or named nurse incorporates key responsibilities for ensuring effective communication between the transferring ward and receiving ward. When patients are transferred from mental health facilities to an acute secondary care setting, mental health medical records should follow the patient. The Mental Health Improvement Group is also working to improve this.”

Source location
2015-0221-Response-by-University-Health-Board
Page 2 · response
Published 12 June 2015
Open published response
18 Sep2014
West London
Concerns raised1
1. Failure to bring potential mental-health indicators to responsible healthcare staff
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.
Respondent positions 1
1. Position
  No practicable steps can be taken concerning Harmondsworth working practices because management responsibility transferred to Mitie.
  Stated by The GEO Group UK LtdUnable to act
AI-generated summary

Brian Christopher Dalrymple · 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

Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.

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 bring potential mental-health indicators to responsible healthcare staff
Wider context from the report
“(1) There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare. Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth. The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth. It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath. ”
Source location
Brian Christopher Dalrymple · 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
No practicable steps can be taken concerning Harmondsworth working practices because management responsibility transferred to Mitie.

Verbatim wording from the response
“As the Contract for the management of Harmondsworth IRC passed to Mitie on 01st September 2014, there is of course no practicable steps GEO can take in relation to the working practices at Harmondsworth.”

Source location
2014-0410-Response-by-The-GEO-Group-UK-Ltd
Page 1 · response
Published 18 September 2014
Open published response
25 Jun2014
Essex
Concerns raised1
1. Failure to ensure messages for mental health staff are read promptly
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

Marion Joanne Turner · 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

Marion Joanne Turner, aged 40, was found hanging at her home on 18 January 2013. A concern was raised that a solicitor’s message about concerns for her mental health was left unread in a pigeon hole until the following day.

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 ensure messages for mental health staff are read promptly
Wider context from the report
“(1) Evidence was given that the day before Ms Turner’s death, her solicitor, as a result of concerns about her mental health, had telephoned into the mental health trust office and left a message for Ms Turner’s CPN. This message remained on a slip of paper, unread, in a pigeon hole until sometime the next day. ”
Source location
Marion Joanne Turner · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission

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

Concerns raised1

Failure to provide access to mental health information during medical treatment

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.2

Concerns raised1

Failure to bring potential mental-health indicators to responsible healthcare staff

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 ensure messages for mental health staff are read promptly

Actions described in response 1

Actions described in response 2

Respondent positions 1