Recurring concern

Failure to reliably assess and diagnose injuries

First to latest report 17 Sep 2013 — 9 Feb 2026

Reports that mention this concern
17
Times this concern has been raised
20
Stated actions linked to this concern
21

What this concern includes

Includes failures of clinical assessment, investigation, diagnostic reasoning or review specifically concerning recognition and diagnosis of traumatic or other physical injuries, including missed or delayed fracture diagnosis and Emergency Department injury-assessment failures.

What is not included
  • Excludes failures concerning diagnosis of medical diseases or conditions without an injury-diagnosis component.
  • Excludes treatment, referral, follow-up or discharge failures where the injury was correctly diagnosed and the deficiency concerns a later care step.
  • Excludes generic staffing, training, communication or documentation deficiencies unless they directly result in unreliable injury assessment or diagnosis.
  • Excludes isolated limitations of a diagnostic test or imaging modality unless the report identifies the resulting failure to assess or diagnose an injury.

Reports and published responses 17 reports

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

  1. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Alfred Grimshaw · 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

    Alfred Grimshaw had an unwitnessed fall at a residential care home on 26 May 2016, was admitted to hospital, and was discharged before being readmitted when a fractured hip was identified. He underwent surgery and died from bronchopneumonia on 6 June 2016. Concerns included the failure to obtain a hip X-ray after the fall and inability to mobilise, failure to report a hip fracture visible on an abdominal X-ray, and lack of evidence that requested physiotherapy or occupational therapy reviews occurred before discharge.

    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 report a visible hip fracture on an x-ray report

    Wider context from the report

    “1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip. 2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it. 3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge. 4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated. ”

    Source location

    Alfred Grimshaw · 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

    Put specific measures in place to reduce the risk of further radiology reporting errors.

    Verbatim wording from the response

    “2. The x-ray report of 27th May (abdominal x-ray to exclude intestinal obstruction) failed to report the evident right hip fracture. The Radiologist who undertook this report is currently under restricted practice, and subject to a clinical review. I am unable to comment further on this matter, but specific measures have been put in place to ensure that the risk of further errors is reduced.”

    Source location

    2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
    Page 1 · response
    Published 28 October 2016

    Open published response

  2. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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 consider intracranial bleeding when assessing new confusion after a fall

    Wider context from the report

    “4. Mrs Tuck had been alert and orientated upon admission on 13 October, and remained so until the afternoon of 16 October, despite her persistently low sodium. When a haematology registrar found her to be confused however, an assumption was made that this confusion was the result of low sodium. It may be that this doctor was unaware of the falls and as a consequence did not consider the possibility that the confusion had been caused by a bleed, but this was the time when a CT scan was indicated. ”

    Source location

    Margaret Emily TUCK · 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

    Discuss serious incidents and morbidity and mortality issues through governance meetings and disseminate learning points to the acute admissions team.

    Verbatim wording from the response

    “7. All Serious Incidents and Morbidity and Mortality issues are discussed at our monthly and quarterly unit Governance meetings. All learning points are discussed and disseminated to all members of the AAU team, including all grades of nursing and medical staff. During the investigation the author of the report sought medical advice from the Clinical Director in Neurosciences. Both AAU and HCoE teams see such cases on a near daily basis, and are expert in dealing with the acutely unwell medical patient. We regret that miscommunication led to the delay in obtaining the relevant scan and believe the measures outlined will address such communication barriers.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 4 · response
    Published 26 July 2016

    Open published response

  3. Mid Kent and Medway

    AI-generated summary

    Lilian Hursell · 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

    Lilian Hursell died at Pembury Hospital on 6 July 2015 from pneumonia contracted following reduced mobility associated with unstable fractured cervical vertebrae after a fall from bed at Maidstone Care Centre. The concerns included bedrails not being securely engaged and the handling of Lilian Hursell after a significant uncontrolled fall before the extent of her injuries had been assessed.

    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 assess injuries after a significant uncontrolled fall before repositioning the patient

    Wider context from the report

    “(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”

    Source location

    Lilian Hursell · 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

    Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.

    Verbatim wording from the response

    “• All staff have been advised that following a fall no person should be moved until a full assessment by a suitably trained person has been carried out.”

    Source location

    Hursell-Response
    Page 2 · response
    Published 1 April 2016

    Open published response

  4. County Durham and Darlington

    AI-generated summary

    Elsie Raper · 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

    Elsie Raper, who had osteoporosis and lived in a care home, suffered multiple falls and fractures, including fractures of the left tibia and fibula after a fall on 21 August 2015. These fractures were not diagnosed until 25 August, during which time she was reported to have been in extreme pain; the cause of death included multiple fractures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in diagnosing fractures during regular clinical visits and examinations

    Wider context from the report

    “(1) That Elsie Raper, being a patient and being subject to regular visits and examination by GP's and nurses, suffered a fracture to her left tibia and left fibula probably on 21st August 2015, which remained undiagnosed until the 25th August 2015. ”

    Source location

    Elsie Raper · 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 24-hour falls observation charts to support closer post-fall monitoring and evidence-based escalation.

    Verbatim wording from the response

    “The inquest highlighted a need for a response from us regarding details of actions taken since Mrs Raper’s death. I can now confirm that the actions listed below have been duly initiated:”

    Source location

    2016-0090-Response-by-Four-Seasons-Health-Care
    Page 1 · response
    Published 4 March 2016

    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

    Refer residents with osteoporosis to the Community Matron after a low-impact fall for review.

    Verbatim wording from the response

    “The inquest highlighted a need for a response from us regarding details of actions taken since Mrs Raper’s death. I can now confirm that the actions listed below have been duly initiated:”

    Source location

    2016-0090-Response-by-Four-Seasons-Health-Care
    Page 1 · response
    Published 4 March 2016

    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

    Initiate prompt ambulance referral for assessment and x-ray when an elderly frail person falls, recognising that minor trauma may cause fracture.

    Verbatim wording from the response

    “1. A fall in an elderly frail person should prompt investigations. A minor trauma may result in a fracture. A prompt referral via an ambulance for assessment (specifically an x-ray) should be initiated without delay.”

    Source location

    elsie-Raper-Response
    Page 1 · response
    Published 4 March 2016

    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

    Include dementia, osteoporosis and other relevant factors in care plans to prompt and support appropriate post-fall assessment.

    Verbatim wording from the response

    “2. The care plan needs to include any factors to prompt and support this action like history of dementia or osteoporosis.”

    Source location

    elsie-Raper-Response
    Page 1 · response
    Published 4 March 2016

    Open published response

  5. Black Country

    AI-generated summary

    Mr Frederick White · 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 Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to 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

    Failure of triage to undertake further and detailed assessment of spinal injury risk

    Wider context from the report

    “(2) Evidence emerging from the inquest suggested that the initial failure to immobilise the patient continued when he arrived at Hospital and the triage process failed to adequately assess the risk again. It appears the triage process is heavily reliant upon the handover from the paramedic crew without further and detailed assessment. ”

    Source location

    Mr Frederick White · Prevention of Future Deaths report
    Page 2 · 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

    Delays in diagnosing suspected spinal cord injury

    Wider context from the report

    “(3) It wasn't until five hours after the initial fall that a suspected spinal cord injury was diagnosed. ”

    Source location

    Mr Frederick White · 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

    Review triage nurse training to require grip assessment for specified elderly patients with head injury.

    Verbatim wording from the response

    “• Current triage assessment does not specifically require a grip test. In this incident there is no documentation suggesting that the patient had neck pain or any neurological deficiency. The department recognises that the use of a simple grip test, currently not routinely used by the triage nurses, could be beneficial in identifying neurology where there is a history of a fall.”

    Source location

    2015-0212-Responses
    Page 2 · response
    Published 3 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a business case and risk assessment for a medical rapid-assessment service for ambulance-borne patients.

    Verbatim wording from the response

    “• The Emergency Department was operating at full capacity when the patient arrived, as noted by the Coroner; the patient was seen 2h 41min post admission by a doctor. The Trust aims to see patients of this type within 1 hour and also aims to have senior (middle grade and consultant) medical staff to be able to provide a ‘Rapid Assessment’ of all ambulance-borne patients at arrival.”

    Source location

    2015-0212-Responses
    Page 2 · response
    Published 3 June 2015

    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 investigation concluded that earlier immobilisation and diagnosis would not have prevented this patient’s death.

    Verbatim wording from the response

    “Although the investigation concluded that spinal cord injuries are uncommon and even if the patient had been immobilised and diagnosed earlier, the patient would not have survived. Irrespective of this there are actions which the Trust will take to prevent incidents of this nature in future.”

    Source location

    2015-0212-Responses
    Page 2 · response
    Published 3 June 2015

    Open published response

  6. Blackpool and the Fylde

    AI-generated summary

    Freda Virginia Owens · 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

    Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unrecognised incorrect assumptions about the cause of a patient’s injury

    Wider context from the report

    “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons: 1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was. 2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved. 3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess. 4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved. These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome. ”

    Source location

    Freda Virginia Owens · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Margaret Theresa CORRIGAN · 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

    Margaret Theresa Corrigan fell at home on 18 January 2013 and fractured her odontoid peg; the inquest concluded that her death was accidental and recorded medical causes including infarction, vertebral artery dissection, peg fracture and Clostridium Difficile infection. Concerns included ineffective communication, failure to diagnose the fracture promptly, failure to transfer her to a medical team when appropriate, and issuing an outpatient orthopaedic appointment while she was an inpatient.

    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 diagnose fractures in the Emergency Department

    Wider context from the report

    “2. The patient was seen in the Emergency Department and it was agreed in evidence that the fracture ought to have been diagnosed at that time but it was not, thus meaning the patient was left for a further two days in additional pain and at risk of further spinal damage. ”

    Source location

    Margaret Theresa CORRIGAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

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Data last updated 7 September 2026