Recurring concern

Inadequate safety-netting advice for patients and carers

First to latest report 6 May 2016 — 10 Nov 2025

Reports that mention this concern
29
Times this concern has been raised
30
Stated actions linked to this concern
24

What this concern includes

Includes failures of safety-netting advice provided to patients, parents, carers or receiving care providers after assessment, treatment, discharge or reported deterioration, including advice that is absent, delayed, undocumented, unclear or not tailored to a material suspected condition.

What is not included
  • Excludes failures of clinical assessment, monitoring, diagnosis or treatment where no safety-netting advice deficiency is identified.
  • Excludes generic communication or documentation failures that are not specifically part of safety-netting.
  • Excludes staffing, workload or workforce wellbeing concerns unless the report directly identifies their effect on safety-netting provision.
  • Excludes emergency call-system or escalation-process deficiencies that do not concern advice given to patients, carers or receiving care providers.

Reports and published responses 29 reports

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

  1. North London

    AI-generated summary

    Jacqueline Aarons · 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

    Jacqueline Aarons died at her care home on 19 November 2024 from the consequences of a strangulated umbilical hernia, following vomiting and deterioration over approximately two days. The substantive concerns were the need for a lower threshold for hospital admission for patients with learning disability, face-to-face medical consultation, and clear written safety-netting instructions for care-home staff.

    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 provide written instructions including safety netting advice after consultation

    Wider context from the report

    “Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability There should be a fact to face consultation by a doctor. Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained. ”

    Source location

    Jacqueline Aarons · 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

    NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.

    Verbatim wording from the response

    “In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 14 November 2025

    Open published response

  2. Inner North London

    AI-generated summary

    Billie Diane WICKS · 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

    Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.

    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

    Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern

    Wider context from the report

    “4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. ”

    Source location

    Billie Diane WICKS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.

    Verbatim wording from the response

    “• All new doctors starting in the Emergency Department, now receive a mandatory teaching session at induction focusing on paediatrics and paediatric deterioration and escalation with regular sessions timetabled ongoing to maintain this education.”

    Source location

    Response from Royal Free Hospitals
    Page 2 · response
    Published 17 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update existing patient-information guidance to specifically address safety-netting documentation and advice.

    Verbatim wording from the response

    “RCEM shares your concerns regarding the use of the term ‘safety netting’ in medical notes. This term is only of value if the components of the ‘safety net’ have been documented. RCEM considers the components which relate to safety netting (as opposed to other information which might be provided to the patient) to include: [18]”

    Source location

    Response from Royal College of Emergency Medicine
    Page 2 · response
    Published 17 March 2025

    Open published response

  3. Shropshire, Telford and Wrekin

    AI-generated summary

    William Stephen GREEN · 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 Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.

    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 record prescribed-drug counselling and safety advice

    Wider context from the report

    “(1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during an admission, no written record is ever made anywhere by anyone including pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the possible side-effects or complications as a result of taking a specific prescribed drug; nor is there any written record on what to look out for and what to do in such circumstances and where they can get assistance. ”

    Source location

    William Stephen GREEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.

    Verbatim wording from the response

    “Record of counselling The counselling of a patient in hospital should be undertaken by the medical staff on prescribing the medication, by the nursing staff and pharmacy staff in preparation for discharge. All professions have a role in drug counselling, our pharmacists are the specialists in medication and counselling and have access to additional resources and referral services. Pharmacy led counselling/documentation:”

    Source location

    Response from Shrewsbury and Telford NHS Trust
    Page 1 · response
    Published 4 March 2025

    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

    Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.

    Verbatim wording from the response

    “Informed consent/counselling when prescribing a new medication: Treating clinicians have a duty and responsibility to ensure patients are aware of any material risk associated with planned treatment, this includes significant side effects of medication.”

    Source location

    Response from Shrewsbury and Telford NHS Trust
    Page 2 · response
    Published 4 March 2025

    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

    Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.

    Verbatim wording from the response

    “However, NHS England will take your concern about counselling, and keeping a written record of such counselling, to an appropriate forum for further discussion and consideration of any actions we need to take.”

    Source location

    Response from NHSE
    Page 2 · response
    Published 4 March 2025

    Open published response

  4. Inner South London

    AI-generated summary

    Charlie Marriage · 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

    Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.

    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

    Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis

    Wider context from the report

    “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”. (2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths: (a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply); (b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice); (c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and (d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated. ”

    Source location

    Charlie Marriage · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Essex

    AI-generated summary

    MARY MARGARET WHITLOCK · 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

    Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.

    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 provide safety-netting advice to care homes

    Wider context from the report

    “(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury ”

    Source location

    MARY MARGARET WHITLOCK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. East Riding and Hull

    AI-generated summary

    Colin Wiles · 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

    Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

    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

    Unclear advice to callers about calling emergency services back when concerns continue

    Wider context from the report

    “(2) It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns. ”

    Source location

    Colin Wiles · Prevention of Future Deaths report
    Page 3 · 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

    Local and system concerns fall outside NHS England’s national policy and programme remit.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    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

    Local organisations should address the local and system concerns raised in the report.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    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

    Worsening-condition and 999 callback instructions are standard components of the case exit script.

    Verbatim wording from the response

    “You raised the concern that it does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    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 relevant ambulance service must resolve unclear callback instructions locally as a call-handler training issue.

    Verbatim wording from the response

    “Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If the call is made via a second party, ambulance services should ensure there is a process in place to be assured the caller is able to monitor the condition of the patient, and that they can be called back when the patient is not able to call back or answer a call themselves. If this was not provided in a clear and easy to interpret manner, this is a matter for the relevant ambulance service to resolve locally as a training issue for their call handlers.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    Open published response

  7. North Yorkshire and York

    AI-generated summary

    Stephen Frederick DULLING · 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

    Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident 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 provide practical emergency-care advice to carers

    Wider context from the report

    “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance. 2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police. 3. My concern is that a repetition of such a limited response could present a risk of future deaths to others. ”

    Source location

    Stephen Frederick DULLING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Inner West London

    AI-generated summary

    Samuel Finlay Parkin · 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

    Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate safety-netting for apparently benign abdominal conditions

    Wider context from the report

    “4. St George’s has implemented a change in ‘safety netting’ advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is given inviting that “benign abdominal diagnosis“ does not exclude conditions requiring urgent surgical/medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point. ”

    Source location

    Samuel Finlay Parkin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. East London

    AI-generated summary

    Claire Twinn · 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

    Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.

    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 record clear safety-netting advice to carers

    Wider context from the report

    “2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record. ”

    Source location

    Claire Twinn · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Gateshead and South Tyneside

    AI-generated summary

    William Nichols · 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 Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team 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

    Absence of documented discharge advice on points of access for concerns or complications

    Wider context from the report

    “(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding). ”

    Source location

    William Nichols · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.

    Verbatim wording from the response

    “Patients in advance of admission to hospital for their surgery are to be provided with a Femoral Endarterectomy Patient Information Leaflet providing full explanation of their pathology along with the proposed surgery, post operative course and potential complications. The course of action to be taken by patient, community nursing team or GP being provided with the relevant contact points along with phone number to call (see Appendix 1). This is in addition to providing the same information to the patient on discharge in a leaflet Wound care following arterial surgery (see Appendix 2) and in written communication in the discharge summary headed as “Information to Patient” (see Appendix 3).”

    Source location

    Response from Newcastle Upon Tyne Hospitals NHS Foundation
    Page 1 · response
    Published 7 September 2023

    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

    Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.

    Verbatim wording from the response

    “• Calls from patients about their wounds and the advice given to them should be documented as an entry on e-Records by either the specialist nursing team, or the on-call vascular registrar (or both if they are both involved in the advice), and this entry should be made as close to the time of the call as possible.”

    Source location

    Response from Newcastle Upon Tyne Hospitals NHS Foundation
    Page 2 · response
    Published 7 September 2023

    Open published response

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

Back to top

Data last updated 7 September 2026