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. Inner South London

    AI-generated summary

    Edward Joyce · 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

    Edward Joyce suffered an accidental scalding injury on 19 November 2017 and later developed septic shock from infected burns. He became severely unwell on 22 November and died despite attempts at resuscitation. Concerns included that a temperature of 38.9°C did not trigger an urgent hospital referral and was not recorded when his mother telephoned the hospital, and that parents were not advised to bring him back to 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 provide advice to return to hospital after reported high temperature following a burn

    Wider context from the report

    “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome. (1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital. (2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital. (3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit. ”

    Source location

    Edward Joyce · 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

    Alert the Paediatric Burns Network to the advice so that improvements can be made more widely.

    Verbatim wording from the response

    “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

    Source location

    2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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

    There was no suggestion that a temperature spike was mentioned during the telephone call and then not recorded or acted upon.

    Verbatim wording from the response

    “It is the Trust’s understanding that the evidence from Nurse ████████ explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded / acted on.”

    Source location

    2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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 existing national leaflet already provides nationally accepted burns advice, correct warning signs, and appropriate instructions for parents seeking further care.

    Verbatim wording from the response

    “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

    Source location

    2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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 burns unit can already be contacted by telephone 24 hours a day, every day.

    Verbatim wording from the response

    “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.”

    Source location

    2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    Open published response

  2. Manchester South

    AI-generated summary

    Joan Hanratty · 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

    Joan Hanratty, who had a complex medical history including heart failure, ischaemic heart disease and moderate to severe Chronic Obstructive Pulmonary Disease, developed a chest infection and was prescribed antibiotics and steroids. She collapsed and suffered a cardiac arrest on 28 January 2018 and died in hospital later that day. The principal concern was that the prescribing system did not explicitly advise patients to seek medical advice if their condition did not significantly improve within a specified period after starting treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of explicit patient advice to seek medical advice after insufficient improvement from antibiotic and steroid therapy

    Wider context from the report

    “It was confirmed in the course of evidence given at the inquest that under certain circumstances, patients who have been diagnosed with, and are subject to regular review as a result of, Chronic Obstructive Pulmonary Disease are issued with prescriptions for antibiotics and steroids upon request and without requirement for a telephone or in-person consultation with a doctor. Whilst it is recognised that this practice accords with relevant clinical guidelines, it is a matter of concern that the system currently operated by the practice does not currently include explicit advice to patients that, in the event a significant improvement in condition is not experienced within a specified period of time of beginning antibiotic and steroid therapy, medical advice should be sought. ”

    Source location

    Joan Hanratty · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Avon

    AI-generated summary

    Yazin ELHAJE · 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

    Yazin Elhaje became ill with suspected meningitis, was initially discharged with a diagnosis of sinusitis, deteriorated, and died from bacterial meningitis on 8 October 2017 despite treatment. The principal concern was that discharge safety-netting advice to his parents addressed headaches rather than the differential diagnosis of meningitis.

    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 addressing meningitis when it is part of the differential diagnosis

    Wider context from the report

    “I heard during the inquest that the safety-netting advice on discharge given to Yazin’s parents was in relation to his headaches and not in relation to the differential diagnosis of meningitis. I would ask that consideration is given to the safety-netting advice provided to parents in cases where meningitis has been considered as part of the differential diagnosis as in this case. ”

    Source location

    Yazin ELHAJE · 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

    Implement a safety-netting process and leaflet for families of children presenting with sinusitis, including information about rare complications such as meningitis.

    Verbatim wording from the response

    “Following this incident the Emergency Department governance lead has led the development of an information leaflet to be given to families whose children present with sinusitis that includes information about rare potential complications such as meningitis.”

    Source location

    Response from University Hospitals Bristol NHS Trust
    Page 1 · response
    Published 6 November 2024

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Tomas Kelly · 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

    Tomas Kelly, aged 3, was admitted to hospital after choking and being diagnosed with aspiration pneumonia and a chest infection. After later developing chicken pox, he deteriorated rapidly at home and died in hospital on 22 November 2016; the cause of death was confluent bronchopneumonia. The principal concerns were that his parents may not have been informed about the increased infection risks associated with Down’s Syndrome, and whether children with Down’s Syndrome should routinely be offered chicken pox vaccination.

    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 communicate the increased infection risks associated with Downs Syndrome to parents or carers

    Wider context from the report

    “1. Talking to parents a. I did not have concerns about the medical professionals being aware of the increased risks associated with infection in children with Downs Syndrome. I heard no evidence of the parents being made aware of this however – either when he was discharged from hospital on 22 October 2016 or when he was seen by his GP on 21 November 2016. b. Tomas’ parents said they may have sought additional medical assistance if they had known about these risks. c. Whilst this may be happening to some extent in community paediatrics, it is important for health professionals in acute settings (including primary care) to be advised to share these risks with parents/ carers, so that they can adopt an appropriate threshold for seeking medical assistance. ”

    Source location

    Tomas Kelly · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. North West Wales

    AI-generated summary

    Simon Willans · 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

    Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.

    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 instructions for worsening condition

    Wider context from the report

    “(4) There is insufficient safety netting for this patient. He was not told what to do in the event of a worsening of his condition. The letter to the GP was faxed the day after discharge by which time he had died ”

    Source location

    Simon Willans · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Patricia Forshaw · 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

    Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.

    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

    Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards

    Wider context from the report

    “i. The telephone number on the card given to the deceased when she was discharged from the Hospital related to appointments only but the purpose of the number is ambiguous and when the deceased’s husband telephoned the number on the card in the early hours of the 20th October 2016 he believed he was speaking to the Emergency Department, particularly in view of the fact that he was given advice to give paracetamol to the deceased. Evidence was given at the Inquest that the appointment card was the only documentation given to the deceased when she was discharged and the card does not have any information as to the action to be taken if there is a deterioration in a patient’s condition after discharge. The evidence given by ████████ a Consultant in Emergency Medicine at the Hospital was that if there is a deterioration in condition the patient should not be given treatment advice by telephone and the patient should be advised to telephone 111 or return to the Hospital but ████████ accepted that there is no reference to such action on the card. ”

    Source location

    Patricia Forshaw · 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

    Update outpatient appointment cards with advice to contact NHS 111 or a GP if the patient’s condition deteriorates.

    Verbatim wording from the response

    “information to be ambiguous. I am aware that the Trust’s outpatient appointment card is to be updated to include advice for patients to contact NHS 111 or their GP if their condition deteriorates.”

    Source location

    2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 3 · response
    Published 2 November 2017

    Open published response

  7. Inner North London

    AI-generated summary

    Mariana Hungria Bayam Veiga PINTO · 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

    Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.

    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 communicate expected illness progression and clear action plans to families

    Wider context from the report

    “2. The view of the psychiatrists treating Ms Pinto in the emergency department was that she was suffering cannabis withdrawal, which I heard is generally at its worst during the first three days. Her symptoms were now quiescent, but it would have been very helpful for her family to know that, most particularly as she had taken cannabis the night before, once the lorazepam wore off she might well have a resurgence of symptoms though these were not expected to be as severe as they had been. Worsening advice could then have been delivered in this context, with a clear plan of action. It is a theme I have noticed in deaths such as Ms Pinto’s, that clinicians’ expectations of illness progression are not necessarily communicated effectively to families, to enable families to identify unexpected deterioration and then to act swiftly and appropriately. ”

    Source location

    Mariana Hungria Bayam Veiga PINTO · 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 and consult service users and carers on a written discharge care plan template.

    Verbatim wording from the response

    “It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.”

    Source location

    response-Pinto
    Page 2 · response
    Published 5 April 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

    Implement and provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.

    Verbatim wording from the response

    “It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.”

    Source location

    response-Pinto
    Page 2 · response
    Published 5 April 2017

    Open published response

  8. South Yorkshire (Western)

    AI-generated summary

    Captain James Michael Bedford · 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

    Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Poor safety-netting after attendance and scanning

    Wider context from the report

    “2. The evidence of 'safety-netting' after the first attendance (and/or subsequent attendance for scans) was poor and of considerable concern. As made clear in my written findings this was possibly of relevant as to Captain Bedforth's subsequent decision on seeking medical attention in or upon return from China. ”

    Source location

    Captain James Michael Bedford · 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

    Record in thrombosis nurses’ notes when patients receive the DVT or pulmonary embolism information sheet.

    Verbatim wording from the response

    “2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.”

    Source location

    2016-0368-Barnsley-Hospital-NHS-Trust
    Page 2 · response
    Published 18 October 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

    Audit compliance with recording the provision of patient information sheets.

    Verbatim wording from the response

    “2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.”

    Source location

    2016-0368-Barnsley-Hospital-NHS-Trust
    Page 2 · response
    Published 18 October 2016

    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

    Close medical supervision after discharge following a negative scan is already triggered by the Thrombosis nurse and consultant referral.

    Verbatim wording from the response

    “In relation to your concern regarding the discharge of a patient like Captain Bedforth following a negative scan and whether he requires close supervision by a doctor, this practice is already in place and is triggered by the Thrombosis nurse. The process is that if the Thrombosis Service Sister has concerns regarding a patient they are referred to the consultant for review in the DVT clinic. The Thrombosis Sister has stated that Captain Bedforth’s case is the first case of its kind she has been aware of in the last 15 years. We will be interested to see whether national guidance changes following your letter and would adapt our local guidelines accordingly, if so.”

    Source location

    2016-0368-Barnsley-Hospital-NHS-Trust
    Page 2 · response
    Published 18 October 2016

    Open published response

  9. Inner North London

    AI-generated summary

    Komang Jack SUSIANTA · 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

    Jack was a 17-year-old boy who developed a drug-related psychotic episode after taking cannabis and ecstasy, was detained by police and taken to hospital, and was discharged after assessment. His condition deteriorated after discharge; he later entered a river while being pursued by police and drowned. The principal concern was that the hospital did not communicate to his family the expected recovery, warning signs of recurrence, or when and how to seek urgent professional help.

    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 communicate that recurrence of psychotic symptoms requires significant concern and potentially immediate action

    Wider context from the report

    “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

    Source location

    Komang Jack SUSIANTA · 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 communicate when and how to seek urgent professional help

    Wider context from the report

    “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

    Source location

    Komang Jack SUSIANTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026