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. Manchester West

    AI-generated summary

    Helen Theresa Cannon · 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

    Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.

    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 or paramedic assistance when warranted by a person's condition

    Wider context from the report

    “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain. It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon. ”

    Source location

    Helen Theresa Cannon · 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

    Integrate a pain-assessment profile into the client assessment process and review the revised process with the service committee.

    Verbatim wording from the response

    “1. The seeking of medical assistance associated with the client expressing that she was “aching rather than in pain”. Presuming that a service can operate without the express requirement for a medical assessment, then the procedures in place at the time of the lady’s fall, the staff carried out an assessment of the client, and part of that assessment was to determine whether it was in pain. However it is clear from your concern that there is an ambiguity around the definition of ‘pain’ vs ‘ache’ and we agree that this could potentially blur the outcome of the evaluation. As a consequence a full review of the surrounding process of patient assessment and a ‘pain assessment profile questionnaire’ has been integrated within the process. This has been reviewed and agreed with the service committee at Wigan Council in order to seek their opinion and agreement as to its suitability.”

    Source location

    2017-0260-Response
    Page 1 · response
    Published 8 November 2017

    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

    Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.

    Verbatim wording from the response

    “2. With regard to the second concern expressed, namely the thoroughness of the investigation, we acknowledge, after further review of the documentation, that the review was conducted with the level of rigor and accuracy that the checklist has also been fully reviewed as part of (i) above. We have introduced “STOP” elements to alert the responders where their answers are such that further assistance may be necessary. We have also separated the checklist out into defined areas and made the layout of the checklist easier and larger which we believe will also assist the staff in completing the documentation. Additionally, the responsibility for the second responder to review the accuracy of a colleague’s client assessment has been clarified with all of the staff, and the timeline of the update has been agreed with Wigan Council.”

    Source location

    2017-0260-Response
    Page 2 · response
    Published 8 November 2017

    Open published response
  2. Birmingham and Solihull

    AI-generated summary

    James Albert Harris · 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 Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.

    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 follow the falls protocol requiring immobilisation and medical attention after a painful fall

    Wider context from the report

    “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████ ████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017, although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident. ”

    Source location

    James Albert Harris · 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

    Disseminate the falls protocol to staff and incorporate it into new-staff induction.

    Verbatim wording from the response

    “3) Protocol for falls – this document has been given to all staff and a signed copy is kept on their personnel file. This has also been made part of the induction protocol for new staff.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 1 · response
    Published 2 December 2017

    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 the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.

    Verbatim wording from the response

    “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 2 · response
    Published 2 December 2017

    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

    Add the falls policy to staff-meeting agendas as a lessons-learned item.

    Verbatim wording from the response

    “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 2 · response
    Published 2 December 2017

    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 Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.

    Verbatim wording from the response

    “The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and the appropriate actions to take by following a service users care plan. If care staff fail to read care plans there is a risk that they will not provide the care that is appropriate to a specific service user and thus putting that service user’s safety at risk.”

    Source location

    2017-0334-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 2 December 2017

    Open published response
  3. Manchester North

    AI-generated summary

    David Michael Lee · 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

    David Michael Lee was found unresponsive at home on 18 February 2017 after taking a considerable quantity of diphenhydramine and telling the emergency call handler about this during a 999 call. The call was terminated approximately 30 minutes in, and the report identified a missed opportunity to escalate the response before he became unconscious and died prior to the ambulance’s arrival.

    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 escalate the urgency of requirements for medical assistance

    Wider context from the report

    “That the call was inappropriately terminated and that this may continue in the future. That there was a missed opportunity to escalate the urgency of the requirement for medical assistance due to the call being terminated. Since the call guidance has not been circulated to members of call handling staff regarding in what circumstances it is appropriate to terminate call and when a call handler should, as a matter of best practice, remain on the line with the patient. Such guidance was circulated twice prior to the deceased’s death but was not adhered to on this occasion. That there has been no training given to staff since the deceased’s death to address when it is appropriate to terminate calls with patients. ”

    Source location

    David Michael Lee · 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

    Revise the call-termination guidance and circulate it to all EOC supervisors.

    Verbatim wording from the response

    “Following the inquest the Trust have revised the relevant guidance in respect of incidents where call takers should remain on the line and have circulated this to all EOC Supervisors, with the following key points emphasized as direct learning from this case:”

    Source location

    2017-0432
    Page 2 · response
    Published 28 June 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.

    Verbatim wording from the response

    “EOC Supervisors have subsequently conducted one to one briefings with all call takers in all three EOCs to discuss the guidance and ensure that the practice of terminating calls is fully understood. All call takers are required to provide their signature to confirm that they have read and understood the guidance and its use.”

    Source location

    2017-0432
    Page 2 · response
    Published 28 June 2017

    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 a reminder system to prompt periodic recirculation of call-termination guidance to call takers.

    Verbatim wording from the response

    “To ensure that the guidance is re-circulated to all call takers at appropriate periodic intervals, the Trust’s Operations Director has also put in place a system whereby he will be periodically reminded to request that the EOC Management team complete the above recirculation process, thus ensuring all call takers are regularly reminded of the practices regarding call termination.”

    Source location

    2017-0432
    Page 2 · response
    Published 28 June 2017

    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

    Produce an incident-based case study and use it in scheduled training and workshops for new and existing call takers.

    Verbatim wording from the response

    “To ensure further Trust wide learning, the Trust’s Legal Department are to produce a case study based on this incident and the appropriate use of call terminations, which will be used in scheduled training sessions/workshops across all EOC’s for new and existing call takers; again to reinforce the practices that should be followed in situations such as this.”

    Source location

    2017-0432
    Page 2 · response
    Published 28 June 2017

    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 emergency call was processed correctly and received the correct response code based on the information provided.

    Verbatim wording from the response

    “I am advised that at the inquest, EOC Deputy Sector Manager Angela Lee gave evidence to the Coroner that the emergency call had been audited and it had been established that it had been processed correctly based on the information given to the call taker and the correct response code was obtained. The call taker stayed on the line with Mr Lee for 30 minutes, however due to Mr Lee telling the call taker that he was starting to feel drowsy, the call taker should have stayed on the line with him until the emergency ambulance arrived. Ms Lee confirmed in evidence that this was an individual error and that the call taker has undertaken a reflective learning exercise in order to identify the error made and reflect on her practice for the future.”

    Source location

    2017-0432
    Page 2 · response
    Published 28 June 2017

    Open published response
  4. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · 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

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek expert advice during daytime working hours

    Wider context from the report

    “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications. As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’. ”

    Source location

    Dennis Allen Teesdale · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    QVH disputes that its lack of on-site specialists prevents access to specialist opinion, because agreements with BSUH provide specialist advice and imaging.

    Verbatim wording from the response

    “Queen Victoria Hospital NHS Foundation Trust (“QVH”) is a specialist surgical hospital. We work in close partnership with other provider trusts both providing services on other sites and benefitting from the expertise of clinicians from other provider trusts who work on the Queen Victoria Hospital site.”

    Source location

    Dennis-Teesdale-Response-1
    Page 1 · response
    Published 28 July 2017

    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

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 2017

    Open published response
  5. Cheshire

    AI-generated summary

    Frederick Chisnall · 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

    Frederick Chisnall was subject to a Deprivation of Liberty Order and receiving one-to-one nursing care from agency staff when he died following a myocardial infarction. Concerns were raised about agency staff producing proper documentation, recognising changes in clinical condition, and obtaining urgent medical or nursing help when appropriate; the adequacy of their training was questioned.

    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 obtain medical or nursing help urgently when appropriate

    Wider context from the report

    “During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, I wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. ”

    Source location

    Frederick Chisnall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. South Yorkshire (Eastern)

    AI-generated summary

    John Atkinson · 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 Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team 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 seek doctors' input when presentation or level of risk changes

    Wider context from the report

    “(2) Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input. ”

    Source location

    John Atkinson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Shropshire, Telford and Wrekin

    AI-generated summary

    Ivy Rebecca Morris · 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

    Ivy Rebecca Morris was born with severe perinatal hypoxic ischaemic brain damage and died at home on 3 May 2016 after becoming unresponsive during a feed. The report identified concerns about foetal heart monitoring, failures to follow midwifery guidelines, and potential delays relating to episiotomy support. The inquest concluded that appropriate monitoring during the second stage of labour would have prevented her death, according to the supplied text.

    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 obstetric review for maternal tachycardia

    Wider context from the report

    “(2) Failure to follow midwifery guidelines. a. To confirm assessment of the CTG using the agreed assessment tool. b. The need to request an obstetric review after 1 hour of active pushing. c. The need to request an obstetric review for maternal tachycardia. ”

    Source location

    Ivy Rebecca Morris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. West Yorkshire (Western)

    AI-generated summary

    Kirsty Childs · 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

    Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Absence of a lower threshold for recommending face-to-face medical review

    Wider context from the report

    “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment, and there did not appear to be a lower threshold of recommending a face to face medical review ”

    Source location

    Kirsty Childs · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
  9. Gwent

    AI-generated summary

    Thomas Byron Black · 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

    Thomas Byron Black collapsed and reported feeling unwell while in HMP Usk, but prison officers did not seek medical advice over the weekend. He later deteriorated after collapsing again on 23 February 2015 and was pronounced dead in hospital; the stated medical cause was pulmonary thrombo-embolus associated with deep vein thrombosis and Factor V Leiden mutation.

    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 advice when a prisoner is apparently unwell

    Wider context from the report

    “Prison staff did not seek medical advice when it was apparent that Mr. Black was unwell. ”

    Source location

    Thomas Byron Black · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 escalate NEWS scores to doctors

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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

    Assign a critical care outreach nurse to link the Acute Medical Unit with critical care services.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    Open published response
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Data last updated 7 September 2026