Recurring concern

Unreliable multi-agency communication procedures

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First reported 29 May 2013•Latest report 16 Jun 2026

Definition

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.

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.

Reports: 134
Individual concerns: 145
Date range: 2013–2026
Stated actions: 303

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.

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

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.

18 Mar2019
Norfolk
Concerns raised1
1. Failure to share relevant information and communicate with external agencies
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 5
1. Action
  Instruct all clinical services to review record-keeping and partner-agency communication practices.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
2. Action
  Review working practices for record keeping and communication with partner agencies across clinical services.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
3. Action
  Provide management assurance on actions taken to improve record keeping and partner-agency communication.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
1. Action
  Deliver a learning session on clinicians’ regulatory, legal and professional responsibilities for record keeping and communication.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
2. Action
  Monitor intervention effectiveness through audit, user feedback and quality and safety reviews.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Operational managers are responsible for reviewing record-keeping and partner-agency communication practices and providing assurance of improvement actions.
  Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibility
AI-generated summary

Ellie Jane LONG · 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

Ellie Long was receiving community treatment from the Eating Disorder Service and had diagnoses of Anorexia Nervosa and Depression. She was found hanging in her bedroom on 10 December 2017 and died in hospital on 12 December 2017. The principal concerns were incomplete record keeping and disclosure, and inadequate communication and information sharing with external agencies including her GP and school.

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 share relevant information and communicate with external agencies
Wider context from the report
“2. Communication with External Agencies a) An initial full, updating letter was sent to Ellie’s GP. However no further updating information was sent. A letter was written providing updating information, but this was not sent. No further updating information was sent to the GP by telephone, letter or email. b) The evidence heard is that efforts were made to contact the school by telephone. However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school. c) It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will “remind staff of the importance of recording efforts to share information/maintain communication”. d) Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions. The importance of “recording efforts to share information ...” may not be sufficient to prevent future deaths. It is the importance of sharing information and communicating with external agencies that should be addressed here. Recording of information is dealt with at Point 1 above. ”
Source location
Ellie Jane LONG · 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
Instruct all clinical services to review record-keeping and partner-agency communication practices.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Review working practices for record keeping and communication with partner agencies across clinical services.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Provide management assurance on actions taken to improve record keeping and partner-agency communication.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Deliver a learning session on clinicians’ regulatory, legal and professional responsibilities for record keeping and communication.

Verbatim wording from the response
“Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Monitor intervention effectiveness through audit, user feedback and quality and safety reviews.

Verbatim wording from the response
“The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 14 June 2019
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
Operational managers are responsible for reviewing record-keeping and partner-agency communication practices and providing assurance of improvement actions.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
Open published response
13 Mar2019
Bedfordshire and Luton
Concerns raised1
1. Failure to pass and sufficiently highlight important risk assessment information in communications
This report raised 1 other concern. 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

Mr Mohammed Hussain · 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 Mohammed Hussain died after setting fire to himself inside a car in Luton on 12 March 2018, following deterioration in his mental health and previous overdoses. Concerns included shortcomings in mental health risk assessments, inadequate application of risk assessment training, and failures to share or highlight important information between staff and care providers.

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 pass and sufficiently highlight important risk assessment information in communications
Wider context from the report
“(1) The Trust had carried out a Serious Incident Investigation (SII) into the circumstances of the Mr Hussain’s death which was critical of both the mental health assessments of Mr Hussain carried out by staff on 30 April and 1 May 2018. This meant that 3 individual staff members had misunderstood or misapplied their risk assessment training. (2) I was informed by the Trust that further risk assessment training was carried out by the Trust following Mr Hussain’s death and yet, at the Inquest, both members of staff (although, one has now moved to another Trust) showed little insight into their actions despite the SII ‘s findings and the further training. (3) It was also apparent at the Inquest that important information required for the risk assessment process had not necessarily been passed and/or sufficiently highlighted in communications both between individual Trust staff members and with other care providers ”
Source location
Mr Mohammed Hussain · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Feb2019
Manchester North
Concerns raised1
1. Failure to communicate referral responses, referral updates and community test requests directly to primary care
This report raised 2 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
  Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
2. Action
  Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
  Stated by NHS Oldham CCGStated planned
Respondent positions 1
1. Position
  The community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
  Stated by Pennine Care NHS Foundation TrustOutside remit
AI-generated summary

John Andrew Mellor · 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

John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.

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 referral responses, referral updates and community test requests directly to primary care
Wider context from the report
“That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility. The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe. It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider. ”
Source location
John Andrew Mellor · 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
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.

Verbatim wording from the response
“Prior to commencement of treatment, a letter is now sent to the patient’s GP when the Renal Consultant is considering ESA treatment to make the GP aware of this and to ask if they are able to monitor the patient’s bloods. A return slip is included so that this can be completed and administered efficiently. When SRFT are aware of the GP’s position in respect of the patient’s bloods, an appropriate blood monitoring plan is agreed with the patient at the time of the prescription of ESA. This method enhances the informed consent process for ESA treatment as patients will have an understanding of the full implications of the monitoring required. SRFT’s Electronic Patient Record System (“EPR”) has been updated with a section confirming when a GP has responded in respect of monitoring. If no response is obtained from primary care, this is followed up by the renal clinical team.”

Source location
2019-0053-Responses
Page 2 · response
Published 2 June 2019
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 an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.

Verbatim wording from the response
“The actions being led by the Renal Team at Salford Royal Foundation Trust have been put in place a standard operating procedure to communicate directly with GP’s and ensure a response to any request for blood monitoring or any other service carried out locally. This will require a response from the local GP or provider before the treatment plan is confirmed. The Trust have confirmed that all correspondence with the patient will be copied to the GP. On a longer term implementation is the development of a shared care model – this has been described in a business case to Greater Manchester Medicines Management Group which will then go out to local commissioners.”

Source location
2019-0053-Responses
Page 6 · response
Published 2 June 2019
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 community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.

Verbatim wording from the response
“The Oldham Adult Community Nursing service provides care for patients who are housebound, either permanently or temporarily, requiring treatment in their own home. There is also a Treatment Room service based in clinics across the borough for those patients’ not housebound but requiring District Nursing interventions. The service is commissioned to deliver a phlebotomy service to housebound patients only.”

Source location
2019-0053-Responses
Page 9 · response
Published 2 June 2019
Open published response
13 Feb2019
West London
Concerns raised1
1. Inadequate communication with agencies involved in resident care
This report raised 19 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

Sophie 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

Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

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 communication with agencies involved in resident care
Wider context from the report
“The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”
Source location
Sophie Bennett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Feb2019
Brighton and Hove
Concerns raised1
1. Failure to maintain communication links between healthcare providers and student support services
This report raised 2 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 4
1. Action
  Introduce an online student-support tool providing 24/7 access and oversight of vulnerable or at-risk students.
  Stated by University of SussexStated planned
2. Action
  Reconfigure pastoral support from separate teams into coordinated thematic services with streamlined processes and clarified responsibilities.
  Stated by University of SussexStated in progress
3. Action
  Improve professional-service data sharing, case-note access, links and active referrals across student support services.
  Stated by University of SussexStated completed
1. Action
  Continue working with the GP practice to improve data sharing about student patients and support risk mitigation.
  Stated by University of SussexStated in progress
AI-generated summary

Daniel Alexander Jeremiah BOWEN · 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

Daniel Alexander Jeremiah BOWEN took his own life, as recorded in the inquest conclusion. Concerns included insufficient use of academic advisors to support him with late work and academic pressures, and flawed communication between university departments, his GP or counsellor, and student support 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
Failure to maintain communication links between healthcare providers and student support services
Wider context from the report
“(2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did. ”
Source location
Daniel Alexander Jeremiah BOWEN · 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
Introduce an online student-support tool providing 24/7 access and oversight of vulnerable or at-risk students.

Verbatim wording from the response
“Activity/Action | Timeline for completion Creation of a Well-being and Mental Health Strategy | September 2019 Introduction of an online student support tool to offer all students 24/7-year-round access and oversight of vulnerable or at-risk students | September 2020 (expedited to Jan 2020) Fundamental review of assessment and feedback mechanism to ensure inclusive practice, effective learning experiences and achievement of fair outcomes | June 2021 Utilise learning analytic and business intelligence software to provide real time data, informing practices and allowing for targeted interventions. | September 2021”

Source location
Response from University of Sussex
Page 3 · response
Published 23 February 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
Reconfigure pastoral support from separate teams into coordinated thematic services with streamlined processes and clarified responsibilities.

Verbatim wording from the response
“Reconfiguration of pastoral support The University is reconfiguring its student support provision from separate teams into thematic areas. The objectives of this reconfiguration are:”

Source location
Response from University of Sussex
Page 3 · response
Published 23 February 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
Improve professional-service data sharing, case-note access, links and active referrals across student support services.

Verbatim wording from the response
“Communication and Data Sharing Following Daniel’s death, the University has reviewed and improved its data sharing and appropriate access to case notes and systems to improve the flow of information across the professional service areas. Professional service staff have improved access to necessary information, links and active referral between constituent areas such as: the Student Support Unit (that works with disabled students and those with specific learning differences and mental health conditions), Student Life and the Counselling Service, to facilitate more cohesive support to students and remove barriers to service access.”

Source location
Response from University of Sussex
Page 3 · response
Published 23 February 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
Continue working with the GP practice to improve data sharing about student patients and support risk mitigation.

Verbatim wording from the response
“The University is also continuing to work with the GP’s Practice towards improving data sharing about patient/student service users, to ensure pertinent information and knowledge is available to expert practitioners, working together to support students and mitigate the risk of serious self-harm as far as it is possible to do so.”

Source location
Response from University of Sussex
Page 4 · response
Published 23 February 2024
Open published response
10 Jan2019
Staffordshire South
Concerns raised1
1. Poor communication during transfers between County Hospital and Royal Stoke
This report raised 1 other concern. 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 cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.
  Stated by University Hospitals of North Midlands NHS TrustExisting arrangements considered sufficient
AI-generated summary

Richard John Lockley · 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

Richard John Lockley had throat and neck cancer and sustained falls that resulted in cervical spine fractures. He died in hospital on 11 September 2018, with suitable feeding not arranged before his death. The concerns were poor communication during a proposed transfer between County Hospital and Royal Stoke University Hospital, and difficulties finding a gastroenterology bed at Royal Stoke.

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 communication during transfers between County Hospital and Royal Stoke
Wider context from the report
“(1) Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy. Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. I wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke. ”
Source location
Richard John Lockley · Prevention of Future Deaths report
Page 1 · 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 cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.

Verbatim wording from the response
“2. Managing available beds across both sites is a task which requires constant adjustment and supervision and the Trust has various measures to ensure that patients receive the appropriate treatment with minimal delay. This includes the measures below:”

Source location
2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 24 May 2019
Open published response
14 Dec2018
West Yorkshire (West)
Concerns raised1
1. Failure to share relevant risk information between agencies
This report raised 7 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 6
1. Action
  Update the partnership agreement with South West Yorkshire Partnership NHS Foundation Trust.
  Stated by West Yorkshire Fire and Rescue ServiceStated in progress
2. Action
  Update the West Yorkshire partnership information-sharing agreement with Together Housing.
  Stated by West Yorkshire Fire and Rescue ServiceStated in progress
3. Action
  Maintain responses to referrals concerning people identified as being at risk of fire in their homes.
  Stated by West Yorkshire Fire and Rescue ServiceStated in progress
1. Action
  Update the partnership agreement with West Yorkshire Fire and Rescue Service to include an information-sharing protocol.
  Stated by Together Housing Group LimitedStated completed
2. Action
  Review and agree the inter-agency information-sharing protocol with West Yorkshire Fire and Rescue Service.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progress
3. Action
  Reinforce consent-based information sharing with housing providers and referrals to fire services when fire risks are identified.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated planned
AI-generated summary

BARNABY LUKE AYLWARD · 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

Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.

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 share relevant risk information between agencies
Wider context from the report
“(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency: a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time; b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed; c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist; d) may have been hampered by issues of confidentiality in communications between agencies. If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed. ”
Source location
BARNABY LUKE AYLWARD · 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
Update the partnership agreement with South West Yorkshire Partnership NHS Foundation Trust.

Verbatim wording from the response
“WYFRS has had a formal partnership in place with SWYFT for a number of years. There is a signed agreement dated October 2014 and we have been in the process of updating our partnership agreements following the introduction of the new Safer Communities Strategy in 2017. Our records show that WYFRS have received 86 referrals directly from SWYFT between 2016 and 2018. However, we expect the actual number of referrals from staff working across SWYFT to be higher than this figure as they may refer through their local team or department name but essentially their work falls under the SWYFT umbrella.”

Source location
2018-0387-Responses
Page 2 · response
Published 13 May 2019
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
Update the West Yorkshire partnership information-sharing agreement with Together Housing.

Verbatim wording from the response
“WYFRS started communication with officials from Together Housing in July 2018 to establish a new partnership information sharing agreement to cover West Yorkshire, expanding the current arrangements. Discussions also took place about the development of training for personnel within both organisations to identify the support available within each service. WYFRS Demenia Resources were also shared with Together Housing to establish whether these would be suitable for their employees to support visits and aid the provision of key fire safety messages.”

Source location
2018-0387-Responses
Page 3 · response
Published 13 May 2019
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
Maintain responses to referrals concerning people identified as being at risk of fire in their homes.

Verbatim wording from the response
“Finally, I am assured that our teams are working with partners across the five districts in the effort to provide our prevention services to those who most need it. We accept that there is still progress to be made around information governance and sharing data across organisational boundaries, and we will continue to make an appropriate response to all of the referrals that we receive in relation to people that are identified as being at risk of fire in their homes.”

Source location
2018-0387-Responses
Page 3 · response
Published 13 May 2019
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
Update the partnership agreement with West Yorkshire Fire and Rescue Service to include an information-sharing protocol.

Verbatim wording from the response
“5.3 Partnership Agreement with West Yorkshire Fire and Rescue Service – the existing agreement with Together Housing and WYF&R service has been updated and includes an”

Source location
2018-0387-Responses
Page 5 · response
Published 13 May 2019
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
Review and agree the inter-agency information-sharing protocol with West Yorkshire Fire and Rescue Service.

Verbatim wording from the response
“The Trust currently has an inter-agency information sharing protocol with West Yorkshire Fire and Rescue service, this protocol is currently under review and it is anticipated that this should be agreed by the end of March 2019.”

Source location
2018-0387-Responses
Page 8 · response
Published 13 May 2019
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 consent-based information sharing with housing providers and referrals to fire services when fire risks are identified.

Verbatim wording from the response
“Staff will be reminded through the safeguarding training and information governance training that where a service user is in rented accommodation, consent should be sought from the service user to provide information regarding the condition of the property to the housing provider.”

Source location
2018-0387-Responses
Page 9 · response
Published 13 May 2019
Open published response
5 Dec2018
Black Country
Concerns raised1
1. Inadequate communication of the risks of delayed pessary removal
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 3
1. Action
  Provide pessary information leaflets covering follow-up requirements and risks to every patient attending for insertion.
  Stated by The TrustStated completed
2. Action
  Translate pessary information leaflets into multiple languages.
  Stated by The TrustStated in progress
3. Action
  Share pessary information leaflets with primary care colleagues for use in local consultation rooms.
  Stated by The TrustStated planned
Respondent positions 1
1. Position
  The patient was reviewed at appropriate intervals and listed for pessary-removal surgery, but illness prevented attendance.
  Stated by The TrustDisputes the concern
AI-generated summary

Mrs Sylvia Mitchell · 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 Sylvia Mitchell, a 90-year-old woman, died at Good Hope Hospital on 23 May 2018 after developing urosepsis associated with a fistula caused by an impacted Gellhorn pessary. The report identified inadequate communication and failures to adequately monitor and review the pessary, with delays in its removal contributing to 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
Inadequate communication of the risks of delayed pessary removal
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently. 2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures. 3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis. ”
Source location
Mrs Sylvia Mitchell · 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 pessary information leaflets covering follow-up requirements and risks to every patient attending for insertion.

Verbatim wording from the response
“Every person attending for pessary insertion now receives an information leaflet which clearly outlines the need for follow up appointments and the risks of having a pessary, including ulceration, bleeding and loss discharge. These are being translated into multiple languages. We will share these leaflets with primary care colleagues for provision in consult rooms locally.”

Source location
Response from Sandwell and West Birmingham NHS Trust
Page 1 · response
Published 12 May 2019
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
Translate pessary information leaflets into multiple languages.

Verbatim wording from the response
“Every person attending for pessary insertion now receives an information leaflet which clearly outlines the need for follow up appointments and the risks of having a pessary, including ulceration, bleeding and loss discharge. These are being translated into multiple languages. We will share these leaflets with primary care colleagues for provision in consult rooms locally.”

Source location
Response from Sandwell and West Birmingham NHS Trust
Page 1 · response
Published 12 May 2019
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
Share pessary information leaflets with primary care colleagues for use in local consultation rooms.

Verbatim wording from the response
“Every person attending for pessary insertion now receives an information leaflet which clearly outlines the need for follow up appointments and the risks of having a pessary, including ulceration, bleeding and loss discharge. These are being translated into multiple languages. We will share these leaflets with primary care colleagues for provision in consult rooms locally.”

Source location
Response from Sandwell and West Birmingham NHS Trust
Page 1 · response
Published 12 May 2019
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 patient was reviewed at appropriate intervals and listed for pessary-removal surgery, but illness prevented attendance.

Verbatim wording from the response
“In respect of Mrs Mitchell, I do believe that we attempted to review her at appropriate intervals and listed her for surgery to remove the pessary. Unfortunately she was unwell and unable to attend on the date organised and we requested that both the patient and the GP let us know when she was well enough to undergo surgery. As you know, this did not occur. We apply NHS-standard protocols for the ‘chasing’ of patients in these circumstances.”

Source location
Response from Sandwell and West Birmingham NHS Trust
Page 1 · response
Published 12 May 2019
Open published response
11 Oct2018
East Sussex
Concerns raised2
1. Delay in communicating actual release dates to custodial establishments
2. Failure to inform vulnerable prisoners of their actual release dates promptly
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
  Publish a new recall policy framework retaining the notification requirement and revising the timeframe to one working day.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Dean Louis BARRELL · 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

Dean Barrell was found hanging in his cell at HMP Lewes on 13 February 2017, and the jury concluded that he had died by suicide. He had not been informed that he was due for release on 17 February 2017 and believed he would remain in prison until 29 April 2017. The report identified a seven-day delay in communicating his actual release date as a principal concern, particularly given the vulnerability of prisoners and the potential impact on his 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
Delay in communicating actual release dates to custodial establishments
Wider context from the report
“Dean Barrell clearly thought he was in HMP Lewes for the remainder of his sentence (some 3 months). This was incorrect, as he was due for release on 17 February 2017. Had Mr Barrell been informed sooner and in a timely fashion, he may well have not taken his own life. It took the Prison and Probation Service 7 days to communicate the actual release date to HMP Lewes. HMP Lewes attempted then to communicate this within 3 hours of receipt, but Mr Barrell had by then taken his own life. Fixed term recalls for breach of licence conditions are not complex. By their very nature, they can result in short sentences to be served. Vulnerable prisoners deserve to know what their actual release date is, as soon as possible. A seven day delay as in this case, is simply unacceptable. The communication of the actual release date to a prisoner should, in this technological age, take less than 7 days. ”
Source location
Dean Louis BARRELL · Prevention of Future Deaths report
Page 1 · 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 inform vulnerable prisoners of their actual release dates promptly
Wider context from the report
“Dean Barrell clearly thought he was in HMP Lewes for the remainder of his sentence (some 3 months). This was incorrect, as he was due for release on 17 February 2017. Had Mr Barrell been informed sooner and in a timely fashion, he may well have not taken his own life. It took the Prison and Probation Service 7 days to communicate the actual release date to HMP Lewes. HMP Lewes attempted then to communicate this within 3 hours of receipt, but Mr Barrell had by then taken his own life. Fixed term recalls for breach of licence conditions are not complex. By their very nature, they can result in short sentences to be served. Vulnerable prisoners deserve to know what their actual release date is, as soon as possible. A seven day delay as in this case, is simply unacceptable. The communication of the actual release date to a prisoner should, in this technological age, take less than 7 days. ”
Source location
Dean Louis BARRELL · 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
Publish a new recall policy framework retaining the notification requirement and revising the timeframe to one working day.

Verbatim wording from the response
“This Probation Instruction remains in force; however a new policy framework covering recall actions will be published by the end of 2018. This framework retains the above requirement but, for the sake of clarity, revises the timeframe to one working day.”

Source location
Dean-BARRELL-Response
Page 2 · response
Published 11 October 2018
Open published response
3 May2018
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to conduct nurse-to-nurse discharge communication between hospitals
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
  Require verbal nurse handover alongside written handover when transferring patients between hospitals.
  Stated by University Hospitals of North Midlands NHS TrustStatus unclear
AI-generated summary

Kenneth William Horne · 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

Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

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 nurse-to-nurse discharge communication between hospitals
Wider context from the report
“(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter. (2) There was no nurse to nurse discharge call between the hospitals. (3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital. As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December. ”
Source location
Kenneth William Horne · 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
Require verbal nurse handover alongside written handover when transferring patients between hospitals.

Verbatim wording from the response
“2. Ward staff to ensure that alongside the paper version of handover between UHN M and other hospitals, a verbal handover happens as part of a trusted assessment.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to share relevant information and communicate with external agencies

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.5

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 pass and sufficiently highlight important risk assessment information in communications

Concerns raised1

Failure to communicate referral responses, referral updates and community test requests directly to primary care

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

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

Concerns raised1

Inadequate communication with agencies involved in resident care

Concerns raised1

Failure to maintain communication links between healthcare providers and student support services

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.4

Concerns raised1

Poor communication during transfers between County Hospital and Royal Stoke

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 share relevant risk information between agencies

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.6

Actions described in response 5

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 4

Respondent positions 1

Actions described in response 6