Recurring concern

Failure to seek medical attention when a person's condition warrants it

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First reported 5 Sep 2013•Latest report 16 Jun 2026

Definition

What this concern includes

Includes failures to recognise the need for and promptly seek medical, paramedic or other appropriate clinical assistance when a person's injury, pain, fall, deterioration or other condition warrants it, including failures in care homes and emergency-response settings.

Not included

  • Excludes delays or failures occurring after medical assistance has already been requested, including ambulance attendance or hospital handover delays.
  • Excludes failures limited to the quality of assessment or treatment after medical assistance has been obtained.
  • Excludes failures to seek advice about routine care arrangements where no immediate or clinically warranted need for medical attention is identified.
  • Excludes generic staffing, training, communication or documentation deficiencies unless they directly result in failure to seek warranted medical attention.
Reports
56

Distinct published reports

Individual concerns
61

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
81

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission9
NHS England4
Department of Health and Social Care3
Recipient name withheld3
National Institute for Health and Care Excellence2
University Hospitals Sussex NHS Foundation Trust2
Abbey Care Village1
Adbolton Hall1
Angel Solutions (UK) Ltd1
Appello Careline Limited1
Association of Ambulance Chief Executives1
Barts Health NHS Trust1
Belle Green Court1
Bury Borough Council1
Care First Class (UK) Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Maria Howell · 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

    Maria Howell, a resident of Cranham Court Nursing Home, died in hospital on 28 September 2019 after her RIG tube fell out, reinsertion was delayed, and she later developed peritonitis. The concerns were that the care home lacked qualified nursing staff to reinsert a time-critical RIG tube and that staff did not recognise the need for urgent medical attention when she became critically ill.

    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 staff clinical judgement to recognise the need for urgent medical attention in critically ill people

    Wider context from the report

    “That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention. ”

    Source location

    Maria Howell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 calling paramedics for deteriorating patients

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · 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

    Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.

    Verbatim wording from the response

    “As a response the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be worn on a lanyard alongside individual identification badges, acting as an immediate reminder. These have now been confirmed as having been redistributed across our inpatient sites within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 2 · response
    Published 24 January 2022

    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

    Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.

    Verbatim wording from the response

    “Additionally, the Division is rolling out handheld devices that allow staff to immediately enter physical observations into the NEWS2 electronic system (and patient record). This will automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Mental Health inpatient areas.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 2 · response
    Published 24 January 2022

    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 comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.

    Verbatim wording from the response

    “Two senior staff members have been identified to work with individuals and groups from the Lucy Wade Unit to ensure they fully understand how to undertake comprehensive NEWS2 assessments. The key focus of the sessions is about confidence-building, particularly regarding decision-making at the time of an urgent clinical incident. They will additionally ensure that all staff are supported to recognise signs of an Anaphylaxis reaction and its associated emergency treatment with Adrenaline. This will include individual group training and the completion of medical emergency scenarios to test knowledge and processes in a more realistic, true-life environment. We are initially prioritising the wards in the north of the county and intend to have this area fully compliant with the training target in this area by mid-April 2022.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 2 · response
    Published 24 January 2022

    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

    Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.

    Verbatim wording from the response

    “The primary message to staff, is that they must call for immediate support from the Ambulance service when they recognise that someone’s physical health is rapidly deteriorating, and a medical emergency is or is likely to occur. This has been included clearly within the notification of learning letter already referred to within this response (Appendix 3).”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 6 · response
    Published 24 January 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

    A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.

    Verbatim wording from the response

    “The recommendation from the SI report was to have a “crash bleep”. This was considered but discounted as the duty doctor covers a number of geographical sites and cannot provide an immediate response. Therefore, the response to a medical emergency needs to remain as 999.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 5 · response
    Published 24 January 2022

    Open published response
  3. East London

    AI-generated summary

    Stacey Camille Alexander-Harriss · 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

    Stacey Camille Alexander-Harriss was bitten by a dog on 15 June 2020, became unwell two days later, and was taken to hospital with suspected sepsis. She suffered a cardiac arrest in the early hours of 18 June 2020 and could not be resuscitated; a later blood culture identified Capnocytophagia canimorsus. The concerns included a knowledge gap among attending doctors about this organism and the risks associated with dog or cat bites, as well as a possible need for greater public awareness.

    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 public awareness of the need to seek urgent medical attention after a dog or cat bite when generally unwell with an underlying illness

    Wider context from the report

    “The evidence during the course of the Inquest gave rise to a concern as to a knowledge gap in relation to the organism Capnocytophagia canimorsus. The attending doctors were not familiar with this form of bacteria living within the mouths of dogs and cats and how easy it is to infect people with this organism. A severe traumatic injury is not required for infection to develop. This organism can cause an overwhelming infection in susceptible individuals. The Inquest heard that conditions such as type II diabetes and hepatic steatosis render the individual to a higher risk of serious infection. The inquest heard that raising awareness of this organism and the underlying high risk medical conditions within the medical profession, may prevent future deaths. The Inquest also heard that there may be a need for greater public awareness in relation to the need to seek urgent medical attention if a person suffers from a relevant underlying illness and becomes generally unwell following a dog or cat bite. ”

    Source location

    Stacey Camille Alexander-Harriss · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Inner South London

    AI-generated summary

    Mr Joseph Agnew · 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 Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.

    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 recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness

    Wider context from the report

    “2. For the attention of CoLP, MPS and College of Policing: No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing. ”

    Source location

    Mr Joseph Agnew · 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

    Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.

    Verbatim wording from the response

    “The PCDA places a high level of emphasis on the potential vulnerability of a person who, because of their situation or circumstances, is unable to take care or protect themself from harm or exploitation. This includes the importance of considering the possibility of hidden medical conditions or non-visible signs that may lead to a person being vulnerable. The College has developed a vulnerability learning programme which supports the PCDA programme and can also be used for officers who have not been trained through the PCDA to ensure consistency in learning.”

    Source location

    2021-0055-Response-from-College-of-Policing-Redacted
    Page 4 · response
    Published 1 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

    Align officers’ first-aid training with Metropolitan Police guidance on snoring, airway obstruction, jaw thrust, and breathing monitoring.

    Verbatim wording from the response

    “I would, however, confirm that my instructions are that the first aid training of City of London Police officers will henceforth fall in line with that given to Metropolitan Police officers, who you heard are now trained specifically to recognise that snoring in a person with a reduced level of consciousness is a sign of airway obstruction which must be rectified and are taught to perform the “jaw thrust” that was described to you by ████████ the Metropolitan Police Service’s Senior Adviser, First Aid, Policy, Assurance and Training, in her evidence before you. DCI ████████ has confirmed that this will be thoroughly covered in the first aid training provided to City of London Police officers. Officers will be taught how to monitor breathing and will be taught not to seek to rely on being able to see the casualty’s chest rise and fall.”

    Source location

    2021-0055-Response-from-City-of-London-Police-Redacted
    Page 2 · response
    Published 1 March 2021

    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 programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.

    Verbatim wording from the response

    “The FALP has five modules and the national recommendation is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider). While Module 2 does not seek to provide detailed coverage of all specific medical conditions it does allow officers and staff to make an assessment of the casualty, including the known factors that may present a risk to their health.”

    Source location

    2021-0055-Response-from-College-of-Policing-Redacted
    Page 3 · response
    Published 1 March 2021

    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

    Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.

    Verbatim wording from the response

    “It is recognised that some areas of policing, such as working in custody environments, firearms operations or public order teams, require additional skills and knowledge. The relevant staff have additional FALP training modules available to ensure they are prepared for situations they are likely to encounter in their specialist roles. Additionally, where local force risk assessments identify a critical need, Chief Officers are able to add additional medical training provisions under the advice of local clinical governance.”

    Source location

    2021-0055-Response-from-College-of-Policing-Redacted
    Page 3 · response
    Published 1 March 2021

    Open published response
  5. Nottinghamshire

    AI-generated summary

    Norma Lockton · 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

    Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the 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

    Delays in organising medical assistance for serious deterioration

    Wider context from the report

    “4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening. ”

    Source location

    Norma Lockton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. West Yorkshire Eastern

    AI-generated summary

    June Mavis Winterbottom · 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

    June Mavis Winterbottom, aged 90, lived alone in sheltered accommodation and was found semi-conscious in her own faeces and vomit, covered in pressure sores, after an urgent Adult Social Care referral received no contact. She was taken to hospital and treated for urosepsis, but died later that day. The report identified ineffective urgent-referral handling, unclear accountability, and no safety net for calling an ambulance when Adult Social Care could not respond promptly.

    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 an ambulance escalation safety net when Adult Social Care cannot respond promptly

    Wider context from the report

    “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

    Source location

    June Mavis Winterbottom · 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

    Establish an on-call rota identifying a manager responsible for out-of-hours periods.

    Verbatim wording from the response

    “• A Team Managers on call rota was set up, to ensure that there was always a clearly identified manager responsible for out of hours, whether evenings or weekends.”

    Source location

    2020-0183-Response-from-Wakefield-Council_Redacted.pdf
    Page 3 · response
    Published 19 November 2020

    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

    Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.

    Verbatim wording from the response

    “I trust that the above information addresses the matters of concern you raise, and provides sufficient reassurance that Adult Social Care in Wakefield have already appropriately reviewed our systems following the death of Mrs Winterbottom, and taken action to ensure the robustness of our systems. As a consequence, Adult Social Care do not feel that there are any additional actions which need to be taken resulting from your issuance of the Regulation 28 Report.”

    Source location

    2020-0183-Response-from-Wakefield-Council_Redacted.pdf
    Page 4 · response
    Published 19 November 2020

    Open published response
  7. Staffordshire South

    AI-generated summary

    Keith Graham WHETTON · 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

    Keith Graham WHETTON had an unwitnessed fall in his care home on 7 September 2019, was later found to have a fractured right hip, underwent surgery, and died at the care home on 5 October 2019. Concerns included the delay in seeking medical attention after the fall and the possibility that family members were not informed promptly.

    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 request necessary medical attention

    Wider context from the report

    “You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September. We hope that this has now been taken on board by your home. Additionally, family members felt that they should have been informed earlier about Keith’s fall and I wonder if lessons have been learned here as well. ”

    Source location

    Keith Graham WHETTON · 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 and implement the home's falls policy and procedure with clearer instructions for unwitnessed falls and post-fall actions.

    Verbatim wording from the response

    “I have also reviewed the policy and procedure of falls within the home and spoken with the regional managers regarding unwitnessed falls and the policy and procedure has now been updated and put in place within the home. The policy is now more robust and has clearer instructions on steps to be taken in the event of a fall.”

    Source location

    2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
    Page 1 · response
    Published 7 January 2020

    Open published response
  8. Inner West London

    AI-generated summary

    Barry Jack Gordon Liffen · 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

    Barry Jack Gordon Liffen, who had dementia and other chronic illnesses and was taking anticoagulants, fell at his sheltered accommodation on 10 March 2019 and sustained a head injury causing subdural bleeding. His condition later deteriorated, and he died in hospital on 11 May 2019 after developing recurrent pneumonia. The concerns identified were the need for clinical assessment after falls and when staff observe deterioration in frail residents at Glebelands.

    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 seek clinical assessment when staff note deterioration in residents' health

    Wider context from the report

    “2. That clinical assessment be sought for persons at Glebelands whose health is noted to have deteriorated by staff. ”

    Source location

    Barry Jack Gordon Liffen · 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

    Failure to seek clinical assessment for frail residents following falls

    Wider context from the report

    “1. That clinical assessment be sought for frail persons resident at Glebelands following falls. ”

    Source location

    Barry Jack Gordon Liffen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Surrey

    AI-generated summary

    Mr Charles Knapp · 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 Charles Knapp, who was paraplegic and dependent on care, developed necrotic pressure sores while living at home and later died in hospital on 24 February 2018 from aspiration pneumonia. The concerns included failures by Angel Solutions (UK) Ltd to maintain his hygiene, reposition him, seek medical attention, provide two carers as required, and maintain or supply complete care records; the Coroner was concerned that inadequate care and records could put other service users at risk of future deaths.

    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 seek medical attention for patients’ pressure sores

    Wider context from the report

    “(i) Angel Solutions (UK) Ltd omitted to maintain Mr Knapp’s personal hygiene or regularly reposition him, and thereafter omitted to seek medical attention for the pressure sores. These omissions contributed to the development of the pressure sores and to Mr Knapp’s death. ”

    Source location

    Mr Charles Knapp · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  10. West Sussex

    AI-generated summary

    James William Francis · 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

    James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in seeking out-of-hours medical advice and requesting GP review

    Wider context from the report

    “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition ”

    Source location

    James William Francis · 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

    Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.

    Verbatim wording from the response

    “I also refer to the attached “Request for attendance of GP” policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service and also the importance of clear communications.”

    Source location

    2019-0202-Response-by-Shaw-Healthcare
    Page 3 · response
    Published 23 August 2019

    Open published response
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Data last updated 7 September 2026