Recurring concern

Failure to obtain relevant collateral information from family and social supports

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First reported 10 Jan 2014•Latest report 5 Mar 2026

Definition

What this concern includes

Includes failures to identify, seek, obtain or use relevant collateral information from family, carers, social workers or other directly involved social supports when that information is material to patient assessment, risk management, support or care.

Not included

  • Excludes generic failures to gather information when no family or social-support collateral is involved.
  • Excludes failures concerning continuity of care, handover or referral unless the material deficiency is specifically failure to obtain or use collateral information from family or social supports.
  • Excludes unrelated failures to provide familial support or to balance confidentiality with family involvement where no failure to obtain relevant collateral information is asserted.
  • Excludes clinical-record retrieval or genetic-history investigation unless the report specifically frames it as collateral information from family or social supports.
Reports
37

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
72

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.

NHS England7
Department of Health and Social Care3
East London NHS Foundation Trust3
Metropolitan Police Service3
Ministry of Justice3
Essex Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North East London NHS Foundation Trust2
North London NHS Foundation Trust2
Recipient name withheld2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Browning Street Surgery1
Care Quality Commission1
Cornwall Partnership NHS Foundation Trust1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1

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. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 and properly consider relevant information from parents

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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 the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.

    Verbatim wording from the response

    “With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response
  2. Mid Kent and Medway

    AI-generated summary

    Joanna Bowring · 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

    Joanna Bowring had depression, paranoid delusions and suicidal thoughts and was receiving community mental health support. She died by suicide on 1 June 2015 after being struck by a high-speed train on the rail track at Boxley, Kent, with evidence of significant planning. Concerns included the lack of a clear understanding of available services and a care plan after the initial assessment, carers not being routinely included in risk assessments, and carers not being advised about behaviours indicating increased suicide risk.

    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 routinely include carers and actively seek their views and knowledge in risk assessment

    Wider context from the report

    “(2) Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not actively sought ”

    Source location

    Joanna Bowring · 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

    Provide family-inclusion training across the service line to frontline staff on engaging with families and carers.

    Verbatim wording from the response

    “• That this issue has also been separately discussed by the Trust at its Patient Safety Meetings, with the outcome that the Trust is commissioning a senior psychotherapist with expertise in family therapy to provide bespoke training to the Crisis and Community Mental Health Teams. I am pleased to confirm that Nigel Jacobs, Family Inclusion Project Lead, has started to provide training across the Service Line to all front-line staff on working with Families with the intention that it assists staff in engaging with carers”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 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

    Develop Open Dialogue training so selected staff attend residential training and disseminate their learning to others.

    Verbatim wording from the response

    “• The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care. Medway is one of the two areas where this is being piloted. This is being taken forward currently, with the intention that selected individual will need to attend a 4 week residential course, and that it is envisaged that they will train others in what they have learned. It was accepted that this was the start of a longer term process.”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 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

    Embed learning on engaging separately with patients and carers through clinician meetings, patient-safety meetings, face-to-face meetings and written guidance or policy updates.

    Verbatim wording from the response

    “• That the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 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

    Complete and report an audit of care plans and risk assessments for evidence of carer involvement.

    Verbatim wording from the response

    “• In February an Audit was carried out of care plans and risk assessments for evidence of Carer involvement. This has been carried out and a report of it provided to the Leadership Forum. I enclose recent slides”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 2016

    Open published response
  3. West Sussex

    AI-generated summary

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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

    Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early 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

    Lack of a process for family members to provide views and information to early-discharge decision-makers

    Wider context from the report

    “(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for discharge. ”

    Source location

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  4. Leicester City and South Leicestershire

    AI-generated summary

    William Abel · 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

    William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

    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 relevant family information before taking no further action

    Wider context from the report

    “2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night. ”

    Source location

    William Abel · 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

    Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.

    Verbatim wording from the response

    “Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    Open published response
  5. Wiltshire and Swindon

    AI-generated summary

    Elizabeth Godwin · 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

    Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated 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

    Failure to gather information from family and others involved in mental health assessments

    Wider context from the report

    “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”

    Source location

    Elizabeth Godwin · 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

    Deliver teaching sessions to improve communication with carers and patients and address barriers to family involvement.

    Verbatim wording from the response

    “The Emergency Department continues to raise awareness of the importance of family involvement and relatives’ valuable knowledge of the patient’s wider situation. Teaching sessions, including seven one hour sessions delivered by the clinical psychologist on removing the obstacles to communication with carers and patients, have been delivered.”

    Source location

    2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 1 · response
    Published 19 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

    Add space to the self-harm proforma to record next-of-kin details, relationship and the patient’s contact wishes.

    Verbatim wording from the response

    “In addition, there is an allocated space on the self-harm proforma for information about the patient’s next of kin, their relationship and the patient’s wishes in relation to whether they should be contacted.”

    Source location

    2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 2 · response
    Published 19 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

    Establish guidance and training requiring staff to involve service users, families and carers in CPA and risk assessments.

    Verbatim wording from the response

    “The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 1 · response
    Published 19 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

    Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.

    Verbatim wording from the response

    “The Trust CPA and Risk Policy outlines the requirement that referrals not requiring assessment will be returned to the referrer with referral outcome decision and recommendations for further intervention.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 19 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

    Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.

    Verbatim wording from the response

    “The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 1 · response
    Published 19 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

    Existing AMHP information-gathering guidance is clear, so no further action is proposed in that area.

    Verbatim wording from the response

    “The guidance for AMHP’s in terms of information gathering is very clear and no action is proposed in this area. However, in terms of communication with other organisations, actions to be taken are covered in d) and e).”

    Source location

    2015-0233-Response-by-Wiltshire-Council
    Page 3 · response
    Published 19 June 2015

    Open published response
  6. Inner North London

    AI-generated summary

    Finnulla Catherine MARTIN · 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

    Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left 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 obtain collateral history from family members before concluding the interview

    Wider context from the report

    “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin. ”

    Source location

    Finnulla Catherine MARTIN · 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

    Pilot the mental health assessment proforma and make it available to mental health colleagues.

    Verbatim wording from the response

    “b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 2 · response
    Published 29 April 2015

    Open published response
  7. Staffordshire South

    AI-generated summary

    Pauline Meredith · 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

    Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to listen to family concerns about changed patient behaviour

    Wider context from the report

    “(3) The family’s perceived reluctance by the GP to listen to the concerns expressed by them with regards to the changed behaviour of the patient following the addition of morphine. ”

    Source location

    Pauline Meredith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop structured criteria and a protocol for identifying complex patients who would benefit from discussion at clinical meetings.

    Verbatim wording from the response

    “2) The practice will endeavour in the future to identify complex patients who might benefit from discussion at clinical meetings. The practice is currently considering how to select patients for these”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 8 · response
    Published 10 January 2014

    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 paranoid thoughts were considered unrelated to morphine and more likely associated with stress and previous similar episodes.

    Verbatim wording from the response

    “With regard to ████████ concern about the paranoia being related to the morphine, I did not consider this to be likely. Miss Meredith’s thoughts seem to be a localised paranoia as otherwise her mental state seemed appropriate, according to the information that I had from Miss Meredith and her family. My impression was that it would be very unusual for Morphine to trigger paranoia and her paranoid thoughts were more likely to be a response to stressful situations. Morphine is not usually associated with paranoia or delusions, although can be associated with hallucinations, confusion and agitation. I additionally considered that Miss Meredith’s paranoid thoughts were similar to her previous episodes when she reported paranoid feelings between 2003 and 2006. At that time she had thought that she was being followed by special branch or inspectors from the benefits agency.”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 5 · response
    Published 10 January 2014

    Open published response
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Data last updated 7 September 2026