Recurring concern

Unreliable multi-agency communication procedures

First to latest report 29 May 2013 — 16 Jun 2026

Reports that mention this concern: 134
Times this concern has been raised: 145
Stated actions linked to this concern: 303

What this concern includes

Includes failures of explicitly multi-agency communication procedures that impair the timely, accurate and complete exchange of safety-relevant information between involved agencies, including the anchor's prison-services communication failure.

What is not included

Excludes generic communication, training, staffing or coordination deficiencies where no explicitly multi-agency communication procedure is identified.
Excludes failures confined to a single organisation's internal communication process.
Excludes failures of a separately named pathway, system or hazard when that concern provides the more specific supported boundary.
Excludes neutral descriptions of multi-agency working without an identified unsafe communication condition.

Trends

Reports over time

Reports mentioning this concern, 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.

Department of Health and Social Care17

NHS England17

Ministry of Justice14

HM Prison and Probation Service10

Home Office8

Recipient name withheld6

Metropolitan Police Service5

Association of Ambulance Chief Executives4

East London NHS Foundation Trust4

National Police Chiefs’ Council4

Care Quality Commission3

College of Policing3

Greater Manchester Mental Health NHS Foundation Trust3

Greater Manchester Police3

NHS Greater Manchester Integrated Care Board3

Reports and published responses 134 reports

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

9 Jun2021
Plymouth, Torbay and South Devon
Concerns raised1
1. Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marc David Bennett · 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

Marc David Bennett was distressed by his children being taken into foster care and took his own life at home on 24 May 2020, having fashioned a ligature. The report identified concerns about communication between Devon Partnership Trust staff and Children’s Services during child protection investigations or care proceedings, and about ensuring appropriate support for parents receiving mental health services.

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 improved communication with Children’s Services during child protection investigations or care proceedings planning
Wider context from the report
“Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings, to ensure appropriate support to parents open to DPT services with mental health problems ”
Source location
Marc David Bennett · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Jun2021
Manchester South
Concerns raised1
1. Poor inter-agency information sharing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Darrell Spear · 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

Darrell Leonard Spear died in a fire at his home on 22 September 2020. The fire was probably accidental and accelerated by extensive hoarding and an open conservatory door. Concerns included poor communication and information sharing between agencies, and the absence of a clear strategy to address the fire risk associated with self-neglect and hoarding.

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
Poor inter-agency information sharing
Wider context from the report
“2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife. ”
Source location
Darrell Spear · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 May2021
Liverpool and the Wirral
Concerns raised1
1. Failure of clinical communication between Trusts about unresolved investigations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Mersey and West Lancashire Teaching Hospitals NHS Trust
Stated actions 2
1. Mersey and West Lancashire Teaching Hospitals NHS Trust
  Develop standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.
2. Mersey and West Lancashire Teaching Hospitals NHS Trust
  Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
AI-generated summary

Eva Hayden · 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

Eva Hayden, aged four, developed neutropenia following an illness and later became seriously unwell with fever-like symptoms. She collapsed on 10 January 2020 and died in the emergency department on 11 January 2020; the inquest found sepsis and bone marrow hypoplasia. Concerns included missed follow-up of her neutropenia, inadequate communication between hospitals, and insufficient communication with her parents about infection risks.

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 clinical communication between Trusts about unresolved investigations
Wider context from the report
“b) When Eva missed the appointment at Ormskirk Hospital on the 25th November 2019 for her blood tests – there was no follow up by the hospital as there was an “assumption” that a follow-up orthopaedic appointment for cellulitis would investigate her neutropenia. The assumption was wrong and there was no clinical communication between the Trusts, which would have clarified that investigation of neutropenia had ceased without resolution. The onus for investigations cannot be on a four year old or her parents who were unaware of the potentially fatal implications. ”
Source location
Eva Hayden · 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
Develop standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.

Verbatim wording from the response
“clinic letters to parents. This will be followed up through a routine cycle of audits which will commence in July 2021 to ensure adherence to this directive and additionally to assess the quality of clinical information that is being recorded. We are working closely with Alder Hey team to ensure that families transferred from Alder Hey to Ormskirk for ongoing investigations have an understanding of the reasons and plans.”

Source location
2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
Page 2 · response
Published 18 May 2021
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
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.

Verbatim wording from the response
“10. The circumstances and details of this case have been widely shared. In addition, we are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about the requirements of:”

Source location
2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
Page 3 · response
Published 18 May 2021
Open published response
7 May2021
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses

Birmingham Women'S and Children'S NHS Foundation Trust
University Hospitals of North Midlands NHS Trust
Stated actions 4
1. University Hospitals of North Midlands NHS Trust
  Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
2. Birmingham Women'S and Children'S NHS Foundation Trust
  Scope improvements to recording patient information for patients needing specialist advice while off site.
3. Birmingham Women'S and Children'S NHS Foundation Trust
  Work with the Norse supplier to transition to the system’s latest version and additional features.
1. Birmingham Women'S and Children'S NHS Foundation Trust
  Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
AI-generated summary

Alex Louise Shaw · 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

Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.

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 communicate patients’ clinical condition and observations between clinicians when telephone advice is sought
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate. (2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented. (3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations. ”
Source location
Alex Louise Shaw · 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
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.

Verbatim wording from the response
“1) The paediatric team are in the process of developing a facility on the Trust electronic Iportal System which will provide a structured note ‘Paediatric Advice Proforma’ to aid electronic documentation of conversations between hospitals when seeking advice on patient care; this will include prompts for important discussion points and will have mandatory fields for vital signs (such as heart rate, BP etc.) which will ensure that the clinician includes such information in conversation. Matters are currently being developed with the IT team and we hope to have a solution by September 2021.”

Source location
2021-0141-Response-from-Royal-Stoke-University-Hospital-Redacted
Page 1 · response
Published 7 May 2021
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
Scope improvements to recording patient information for patients needing specialist advice while off site.

Verbatim wording from the response
“It is acknowledged that this will result in inconsistencies in practice and as a result, the Trust’s Chief Clinical Information Officer (CCIO) as Associate Chief Medical Officer for IT and Information, together with the Trust’s Chief Technology Officer and Data Protection Officer for the Trust are scoping how the recording of information pertaining to patients who are not on our premises but who need specialist clinical advice can be improved.”

Source location
2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
Page 2 · response
Published 7 May 2021
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
Work with the Norse supplier to transition to the system’s latest version and additional features.

Verbatim wording from the response
“We have a limited deployment of an electronic product called Norse. This facilitates a typed ongoing conversation between a clinician’s at this Trust and at another centre. This system includes some features including an ability for our staff to request baseline information at the start of the conversation and include other clinicians as appropriate in the conversation. At conclusion of the discussion, it is then possible to retain the detail of the dialogue.”

Source location
2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
Page 2 · response
Published 7 May 2021
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
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.

Verbatim wording from the response
“We have a limited deployment of an electronic product called Norse. This facilitates a typed ongoing conversation between a clinician’s at this Trust and at another centre. This system includes some features including an ability for our staff to request baseline information at the start of the conversation and include other clinicians as appropriate in the conversation. At conclusion of the discussion, it is then possible to retain the detail of the dialogue.”

Source location
2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
Page 2 · response
Published 7 May 2021
Open published response
15 Apr2021
Manchester South
Concerns raised1
1. Lack of specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 1
1. Department of Health and Social Care
  Because the patient was technically not admitted, the Trust did not need to invoke its hospital discharge process.
  Disputes the concern
AI-generated summary

Ailsa Stewart · 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

Ailsa Stewart, who was bed-bound, lived alone and relied on domiciliary carers, was left without domiciliary care after her care package was suspended following a hospital assessment. She was found gravely ill at home on 29 April 2019 and subsequently died in hospital; the inquest recorded that her death was from natural causes, contributed to by neglect. The report identified concern that there was no cohesive national framework or guidance governing suspension of domiciliary care packages and the communication of responsibilities between agencies.

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 specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission
Wider context from the report
“The court heard evidence as to an extensive range of actions which local agencies have taken in response to Ms Stewart’s death to try and reduce the risk of a similar set of circumstances occurring again. That said, it was clear from the evidence that in England, family members play an essential part in ensuring continuity of care is maintained by sharing information between different agencies, and facilitating the co-ordination of care provided to vulnerable patients, particularly in circumstances where unplanned hospital attendances are required. It is a matter of concern that no cohesive national framework or guidance exists across health and social care, to prescribe the circumstances in which a domiciliary care package can be suspended, or sets out specific rules as to the roles and responsibilities of particular agencies to convey information when a vulnerable patient is sent home from an urgent care setting without having formally been admitted. ”
Source location
Ailsa Stewart · 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
Because the patient was technically not admitted, the Trust did not need to invoke its hospital discharge process.

Verbatim wording from the response
“NHSE and NHSI have informed my officials that technically Ms Stewart had not been admitted to hospital and it was therefore not necessary for the Trust to invoke their discharge process.”

Source location
2021-0110-Response-from-Department-of-Health-Social-Care-Redacted
Page 2 · response
Published 15 April 2021
Open published response
26 Mar2021
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Hart Care Limited
Stated actions 1
1. Hart Care Limited
  Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
AI-generated summary

Clara Ellen Freeman · 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

Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.

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 care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency
Wider context from the report
“(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition. It is requested that the training for care and nursing staff be reviewed to consider; a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency b) Accurate recording of medical information including vital signs c) Awareness of the risks of medical complications following falls and long lies. ”
Source location
Clara Ellen Freeman · 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
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.

Verbatim wording from the response
“In accordance with the Regulation 28 Report to Prevent Future Deaths dated 26th March 2021, I write to confirm that we have taken action and all our staff members who are in charge of shifts in the home have attended First Aid Training on the 11th and 13th May 2021 in addition to the mandatory training programme we have in place.”

Source location
2021-0085-Response-from-Hart-Care-Redacted
Page 1 · response
Published 30 March 2021
Open published response
26 Mar2021
Manchester North
Concerns raised1
1. Failure of communication processes to ensure appreciation of the significance of prefix numbers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

National Highways
Stated actions 2
1. National Highways
  Implement clearer free-text source details in electronic incident-log transfers between Highways England and police organisations.
2. National Highways
  Brief regional operations staff and North West police operators on free-text incident-log entries and disseminate the briefing nationally as best practice.
AI-generated summary

Lee David Marsden · 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

Lee David Marsden was struck by a vehicle on the M66 motorway on 20 December 2019 after accessing the carriageway on foot, sustaining fatal injuries. Concerns included delays in activating a 30 mph warning, ineffective communication between Highways England and North West Motorway Police Group, and the absence of an internal review by Highways England.

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 communication processes to ensure appreciation of the significance of prefix numbers
Wider context from the report
“2. The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126 ”
Source location
Lee David Marsden · 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
Implement clearer free-text source details in electronic incident-log transfers between Highways England and police organisations.

Verbatim wording from the response
“Highways England and the NWMPG have agreed that going forward details relating to the source of information should be clearer and relayed between”

Source location
2021-0084-Response-from-Highways-England-Redacted
Page 1 · response
Published 30 March 2021
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
Brief regional operations staff and North West police operators on free-text incident-log entries and disseminate the briefing nationally as best practice.

Verbatim wording from the response
“Highways England will brief the circumstances of this incident together with the outcome of our review to the North West Regional Operations Centre staff. The Police Operators within the NWMPG (Cheshire, Merseyside, Greater Manchester), as well as Lancashire Constabulary and Cumbria Constabulary will similarly be briefed. This joint approach will cover all the police forces operating within the North West geographic area of the Strategic Road Network.”

Source location
2021-0084-Response-from-Highways-England-Redacted
Page 2 · response
Published 30 March 2021
Open published response
9 Nov2020
Surrey
Concerns raised1
1. Failure to communicate MARAC-identified risks and planned safeguarding measures to general practitioners
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Surrey County Council
Stated actions 1
1. Surrey County Council
  Assist Surrey Police with its detailed review of MARAC workings.
Respondent positions 1
1. Surrey County Council
  Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.
  Redirects responsibility
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 died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.

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 communicate MARAC-identified risks and planned safeguarding measures to general practitioners
Wider context from the report
“4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner. ”
Source location
Name not published · 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
Assist Surrey Police with its detailed review of MARAC workings.

Verbatim wording from the response
“Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

Source location
Response to Surrey coroner area - Prevention of future deaths report
Page 1 · response
Published 7 October 2022
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
Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.

Verbatim wording from the response
“Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

Source location
Response to Surrey coroner area - Prevention of future deaths report
Page 1 · response
Published 7 October 2022
Open published response
26 Aug2020
Lincolnshire
Concerns raised1
1. Failure to communicate immediate family concerns to relevant care agencies
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Lincolnshire Partnership NHS Foundation Trust
Stated actions 3
1. Lincolnshire Partnership NHS Foundation Trust
  Reinforce that clinicians may receive information from families and carers without patient consent to share information.
2. Lincolnshire Partnership NHS Foundation Trust
  Implement robust communication, information-sharing and aligned clinical pathways with We Are With You.
3. Lincolnshire Partnership NHS Foundation Trust
  Reinforce family and carer involvement in care, including receiving carer information and sharing information with patient consent.
AI-generated summary

Toby Peter Edward Nieland · 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

Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

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 communicate immediate family concerns to relevant care agencies
Wider context from the report
“1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care; ”
Source location
Toby Peter Edward Nieland · 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
Reinforce that clinicians may receive information from families and carers without patient consent to share information.

Verbatim wording from the response
“In cases where explicit consent has not been given by a patient to share their sensitive personal information; the Trust has taken action to remind clinicians that information from families and carers can still be received. The Carers Lead for the Trust continues to work with the Divisional Leads; Learning and Development and also the Communications Team to reinforce the message to staff that they can still receive information from Carers and Families even when consent is not given from the patient to share information. In Mr Nieland’s case it was unfortunate the Trust were not made aware of any concerns held by the family, however there is the clear commitment to learn from this and to consider what needs to be in place to strengthen communication and to actively encourage feedback.”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020
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
Implement robust communication, information-sharing and aligned clinical pathways with We Are With You.

Verbatim wording from the response
“The Trust and ‘We Are With You’ (as Addaction is now called) will work together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways and protocols, with the aim to make collaborative working between the two organisations standard practice. The Trust confirms this is part of its work plan over the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division.”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020
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
Reinforce family and carer involvement in care, including receiving carer information and sharing information with patient consent.

Verbatim wording from the response
“iv. To reinforce and further embed the important role of carers and family members in providing the right quality care to patients and to support carers in getting involved with their loved ones’ care, including receiving information from carers and sharing information with consent from patients. Lead: Service Manager for Carers and Peer Support – Ongoing”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 8 · response
Published 26 October 2020
Open published response
20 Dec2019
Manchester City
Concerns raised1
1. Failure to provide coordinated interpreted communication about prisoner transfers
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

HM Prison and Probation Service
Stated actions 1
1. HM Prison and Probation Service
  Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.
AI-generated summary

Tomasz Nowosad · 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

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide 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 coordinated interpreted communication about prisoner transfers
Wider context from the report
“5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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
Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.

Verbatim wording from the response
“Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.”

Source location
2019-0445-Response-from-HMPPS
Page 2 · response
Published 8 January 2020
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning

Concerns raised1

Poor inter-agency information sharing

Concerns raised1

Failure of clinical communication between Trusts about unresolved investigations

Linked response

Stated actions 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 communicate patients’ clinical condition and observations between clinicians when telephone advice is sought

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Lack of specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission

Linked response

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

Concerns raised1

Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency

Linked response

Stated actions 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 of communication processes to ensure appreciation of the significance of prefix numbers

Linked response

Stated actions 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 communicate MARAC-identified risks and planned safeguarding measures to general practitioners

Linked response

Stated actions 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 communicate immediate family concerns to relevant care agencies

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Stated actions 2

Stated actions 4

Respondent positions 1

Stated actions 1

Stated actions 2

Stated actions 1

Respondent positions 1

Stated actions 3