1 Jun 2026 Katharine Emma Corrigan · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to respond appropriately to family concerns and communicate the patient’s treatment wishes View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Katharine Emma Corrigan · 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
Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond appropriately to family concerns and communicate the patient’s treatment wishes
Wider context from the report “10. The Family had raised repeated concerns that Ms Corrigan was not receiving appropriate treatment on the ward and about the risks to herself, verbally and in writing. The Family correspondence contained communications evidencing their concerns emanating from Ms Corrigan herself in text messages to the responsible clinician and other staff. Ms Corrigan was encouraged to undergo intensive psychoanalytical psychotherapy even though she explained she did not feel ready and her family did not know or understand about how rare this form of therapy is and relied on her treating clinical team. They were encouraged to fund this and convey her to the therapy in the community without an understanding that Ms Corrigan did not wish for it.
” Source location Katharine Emma Corrigan · Prevention of Future Deaths report
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22 May 2026 Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report Somerset
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Concerns raised 1
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jacqueline Marie Antoinette Frehe · 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 Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward ; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Source location Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Verbatim wording from the response “To address this, we are strengthening expectations for staff to clearly document, escalate, and act upon concerns raised by families. This will include:” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Verbatim wording from the response “4. Visual Identification and Safety Communication” Source location Response from Somerset NHS Foundation Trust
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16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
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Concerns raised 1
Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Society For Genetic Medicine Department of Health and Social Care NHS England Sudden Cardiac Arrest UK
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS England
Revise the Clinical Genetics service specification.
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NHS England
Consider how additional Clinical Genetics capacity and infrastructure could be achieved to reduce preventable morbidity and mortality.
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British Society For Genetic Medicine
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
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British Society For Genetic Medicine
Support dissemination of guidance on consent and confidentiality in genomic medicine.
View source
NHS England
Revise the Clinical Genetics service specification and consider ways to increase capacity and infrastructure for proactive family contact.
View source
British Society For Genetic Medicine
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
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Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” Source location Adam Ankers · Prevention of Future Deaths report
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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 Clinical Genetics service specification.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider how additional Clinical Genetics capacity and infrastructure could be achieved to reduce preventable morbidity and mortality.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
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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 Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Verbatim wording from the response “BSGM’s role in this situation is to raise awareness of the need to share important information about genetic diagnosis and the results of genomic tests. BSGM will also contribute to documents such as ‘Consent and confidentiality in genomic medicine’ and to help in its dissemination. BSGM through its members can also help to influence service development in both specialist genetic services and also in more mainstreamed genetic medicine. Work is currently ongoing by NHS England to review the service specification for the Clinical Genomics Services and the working group involved in this work includes many BSGM or its contributory groups (Clinical Genetics Society and Association of Genetic Nurses and Counsellors) officers.” Source location Response from British Society for Genetic Medicine
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support dissemination of guidance on consent and confidentiality in genomic medicine.
Verbatim wording from the response “The Joint Committee on Genomics in Medicine (JCGM) is a joint committee of BSGM, Royal College of Physicians, Royal College of Pathologists. In 2019, JCGM released the 3rd edition of the guidance document ‘Consent and confidentiality in genomic medicine’. This was written by ████████ who has given evidence in this inquest, and ████████. Many of the principles in practice within specialist clinical genetics and genomic practice are supported by the principles of this document. Genetic testing is now more embedded in clinical practice outside of the specialist genetics workforce. There are many educational activities underway to equip non genetics specialists to deliver their specific element of genetic medicine, for example by giving patients information about their genetic risk and by requesting genetic testing, giving the result and explaining the implications to the wider family.” Source location Response from British Society for Genetic Medicine
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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 Clinical Genetics service specification and consider ways to increase capacity and infrastructure for proactive family contact.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The “Clinical Genetics Transformation Programme”, who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England
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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 Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Verbatim wording from the response “BSGM’s role in this situation is to raise awareness of the need to share important information about genetic diagnosis and the results of genomic tests. BSGM will also contribute to documents such as ‘Consent and confidentiality in genomic medicine’ and to help in its dissemination. BSGM through its members can also help to influence service development in both specialist genetic services and also in more mainstreamed genetic medicine. Work is currently ongoing by NHS England to review the service specification for the Clinical Genomics Services and the working group involved in this work includes many BSGM or its contributory groups (Clinical Genetics Society and Association of Genetic Nurses and Counsellors) officers.” Source location Response from British Society for Genetic Medicine
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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 Genetic or hereditary disease cascade communication falls outside the peer-support charity’s remit.
Verbatim wording from the response “Our group aim focusses on the consequence and recovery from a sudden cardiac arrest and not the cause. Whilst discussions do take place surrounding cause, this is minimal and not the focus or remit off our group.” Source location Response from Sudden Cardiac Arrest
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical professionals should lead case-by-case cascade communication of genetic or hereditary disease information.
Verbatim wording from the response “We fully understand that our survivor members may have concerns surrounding potential genetic or hereditary disease, however, feel that the cascade of this information should be led by medical professionals at source on a case to case basis.” Source location Response from Sudden Cardiac Arrest
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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 Lack of medical qualifications prevents commenting on initiatives concerning genetic or hereditary disease cascade communication.
Verbatim wording from the response “If required, we could consider any initiative to support POINT E, however do not feel that we are either qualified to comment on such matters, or that it is within our remit as a peer to peer support charity.” Source location Response from Sudden Cardiac Arrest
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The claimed evidence that cascade genetic-risk communication fails to reach more than half of affected family members could not be located.
Verbatim wording from the response “NHS England have reviewed your concern that cascade communication of genetic/hereditary disease “does not reach more than half of those in families that need to know about it” but have been unable to locate the literature or evidence where this originated. Information sharing between family members of a particular genetic risk of a condition will be different for different conditions.” Source location Response from NHS England 2
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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 Clinical services lack sufficient capacity and infrastructure to proactively contact lower-risk relatives outside specified high-risk situations.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
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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 Implementing service change is outside the organisation’s remit; it can only influence how genetic services are delivered.
Verbatim wording from the response “While many members of BSGM sit in positions of leadership within clinical genetics services and work within cardiac genetic services, it has no remit to implement service change but rather to influence how services are delivered.” Source location Response from British Society for Genetic Medicine
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The evidence supporting the claim that cascade communication fails to reach more than half of affected family members could not be located.
Verbatim wording from the response “NHS England have reviewed your concern that cascade communication of genetic/hereditary disease “does not reach more than half of those in families that need to know about it” but have been unable to locate the literature or evidence where this originated. Information sharing between family members of a particular genetic risk of a condition will be different for different conditions.” Source location Response from NHS England
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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 Clinical services lack sufficient capacity and infrastructure to contact lower-risk family members proactively.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The “Clinical Genetics Transformation Programme”, who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England
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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 will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England officials. They have confirmed that NHS England will respond to you directly on POINT A, POINT C and POINT E.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited capacity, variable infrastructure and regulatory restrictions can prevent clinical teams from contacting or testing at-risk relatives directly.
Verbatim wording from the response “Despite this, we acknowledge that the sharing and dissemination of genetic information within families may not be easy and is influenced by the complexities of family structures and dynamics as well as systemic constraints. Efforts are made to encourage and facilitate timely sharing of information and cascade testing in families. Barriers to this include limited service capacity, variable infrastructure and jurisdictional or cross border regulatory frameworks that restrict if, how and when clinical teams can contact or offer testing to at risk relatives directly.” Source location Response from British Society for Genetic Medicine
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2 Apr 2026 David ABBOTT · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Ineffective communication processes for patient and family engagement in clinical decisions View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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David ABBOTT · 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 ABBOTT underwent surgery at West Suffolk Hospital on 25 October 2023 and was discharged the following day with advice that he interpreted as meaning he should not mobilise. He remained immobile for four days, subsequently developed deep vein thrombosis and pulmonary embolism, and died in cardiac arrest at home on 29 November 2023. Concerns included potentially incorrect discharge advice, inadequate recording of important advice, and ineffective communication between hospital staff, patients and families.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ineffective communication processes for patient and family engagement in clinical decisions
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error.
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment .
” Source location David ABBOTT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore wider rollout of the “write to me rather than about me” approach across the Trust.
Verbatim wording from the response “Recently, as a continuation of this project, WSFT is exploring how best it can utilise the “write to me rather than about me” paradigm. This has been advocated by the Academy of Medical Royal Colleges since 2018 and has just been updated. A link to the further guidance can be found here: https://www.aomrc.org.uk/wp-content/uploads/2026/02/Please_write_to_me_0226.pdf” Source location Response from West Suffolk NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Call 4 Concern/Martha’s Rule programme across all inpatient areas, including structured wellness questions and escalation for independent clinical review.
Verbatim wording from the response “As reported previously, we would like to highlight the continued work introducing the national ‘call for concern’ and Martha’s rule programme. Since Mr Abbott’s death on 29 November 2023, the Trust has adopted the national Call 4 Concern / Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient-wellness question, enabling both doctors and nurses to engage proactively with patients regarding their condition and any emerging concerns.” Source location Response from West Suffolk NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend hospital visiting hours to 8pm to improve relatives’ participation in ward-round communication.
Verbatim wording from the response “In addition to the above, since April 2026 WSFT has extended its visiting hours from 10am to 8pm. This will support improved communication with relatives and patients, as the next of kin can be present during ward rounds and thus increasing the opportunity for face-to-face communication with consultant teams.” Source location Response from West Suffolk NHS Foundation Trust
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6 Feb 2026 Michaela FINCH · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to communicate family concerns to assessing clinicians View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michaela FINCH · 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
Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.
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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 family concerns to assessing clinicians
Wider context from the report “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal .
” Source location Michaela FINCH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Verbatim wording from the response “The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan.” Source location 2026-0064 - Response from Greater Manchester Mental Health
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20 Jan 2026 Linda Fury · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Ward-round processes failing to facilitate private family disclosure of risk concerns to the multi-disciplinary team View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Pennine Care NHS Foundation Trust
Improve MDT ward-round documentation to capture patient and carer views, including mandatory use of the ward-round document.
View source
Pennine Care NHS Foundation Trust
Pilot a carer questionnaire to inform improvements to the MDT ward-round process.
View source
Pennine Care NHS Foundation Trust
Roll out the standardised pre-ward-round patient and carer form from pilot sites to all inpatient wards.
View source
Pennine Care NHS Foundation Trust
Strengthen confidential routes for carers to share risk information outside ward rounds, with documentation in the PARIS carer space.
View source
Pennine Care NHS Foundation Trust
Update and distribute information leaflets explaining confidential routes for carers to share concerns.
View source
Pennine Care NHS Foundation Trust
Update confidentiality policy, staff and carer guidance, and carer-awareness training through the Triangle of Care working group.
View source See 3 more actions
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Linda Fury · 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
Linda Fury, who had a long history of severe and enduring mental illness, died at home on 3 May 2025 after being discharged from hospital following the rescinding of her detention. The report identifies concerns about the discharge decision, including insufficient consideration of family information and the failure to trial home leave or provide step-down care. It also raises concerns about the insufficient rigour of the Trust’s investigation and ward-round processes not routinely allowing families to share risk concerns privately.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ward-round processes failing to facilitate private family disclosure of risk concerns to the multi-disciplinary team
Wider context from the report “2. I am concerned that the current processes for ward rounds do not routinely facilitate an opportunity for family members to disclose any concerns relevant to risk privately to the multi-disciplinary team .
” Source location Linda Fury · Prevention of Future Deaths report
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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 Improve MDT ward-round documentation to capture patient and carer views, including mandatory use of the ward-round document.
Verbatim wording from the response “We have initiated trust-wide improvement work to ensure Multi-Disciplinary Team (MDT) documentation reliably captures patient and carer views. The identified aims of this are to:” Source location Response from Pennine Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot a carer questionnaire to inform improvements to the MDT ward-round process.
Verbatim wording from the response “We have initiated trust-wide improvement work to ensure Multi-Disciplinary Team (MDT) documentation reliably captures patient and carer views. The identified aims of this are to:” Source location Response from Pennine Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the standardised pre-ward-round patient and carer form from pilot sites to all inpatient wards.
Verbatim wording from the response “A standardised Pre-Ward-Round Form for Patients and Carers has been developed with the support of the Culture of Care programme, who provide quality improvement (QI) coaches and lived experience support. These have been implemented in pilot sites and is planned to be rolled out to all inpatient wards. The form enables both patients and carers to feel heard when they are not able to attend ward round or feel unable to speak in a ward round due to feeling uncomfortable or worrying about damaging relationships with their loved ones.
The form is able to explore:” Source location Response from Pennine Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen confidential routes for carers to share risk information outside ward rounds, with documentation in the PARIS carer space.
Verbatim wording from the response “In addition to this, we are strengthening the expected standards through which carers can share risk-related information outside the main ward-round or visiting environment, this includes an ability to contact the nurse-in-charge or delegated clinician privately, dedicated email/telephone routes for sharing concerns, the option to request a short one-to-one discussion with the MDT outside of the formal ward round. All information is documented in the PARIS carer space, ensuring visibility across the MDT.” Source location Response from Pennine Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and distribute information leaflets explaining confidential routes for carers to share concerns.
Verbatim wording from the response “In addition to this, we are strengthening the expected standards through which carers can share risk-related information outside the main ward-round or visiting environment, this includes an ability to contact the nurse-in-charge or delegated clinician privately, dedicated email/telephone routes for sharing concerns, the option to request a short one-to-one discussion with the MDT outside of the formal ward round. All information is documented in the PARIS carer space, ensuring visibility across the MDT.” Source location Response from Pennine Care NHS Foundation Trust
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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 confidentiality policy, staff and carer guidance, and carer-awareness training through the Triangle of Care working group.
Verbatim wording from the response “As part of the trust-wide Triangle of Care work, Standard 3: Confidentiality is being actively worked on. The Triangle of Care is a nationally recognised framework developed by the Carers Trust to strengthen collaboration between service users, carers, and mental health professionals. It is built on six key standards that ensure carers are identified, included, informed, and supported throughout the care” Source location Response from Pennine Care NHS Foundation Trust
Open published response
15 Oct 2025 Tony Montana Duncan · Prevention of Future Deaths report City of London
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Concerns raised 1
Failure to alert relevant services, the GP, or family about a high-risk patient’s departure View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Tony Montana Duncan · 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
Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
Wider context from the report “3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation .
” Source location Tony Montana Duncan · Prevention of Future Deaths report
Open source report
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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 documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
Verbatim wording from the response “Ideally, the PLN would have sought Mr Duncan’s consent to contact a named person/carer, ideally his mother with whom he lived, but did not do this; the AAR has made a recommendation to address this omission by embedding ‘carer contact’ in the Liaison Psychiatry departmental handover board; this must be done and documented before patients can be discharged. The Trust is accredited under the Triangle of Care initiative led by the Carers Trust and endorsed by NHS England, which seeks to implement six key standards required to achieve better collaboration and partnership with carers, including identification of carers at first contact; the implementation of this in the ED can be difficult for reasons outlined in the AAR, and this extra flag is intended to provide further operational support for future patient cases.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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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 Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
Verbatim wording from the response “The AAR did note that adult patients with mental capacity to make the relevant decision may well decline or refuse a request to contact their family, but in this case there is no documentation that this discussion took place. Family members are often able to provide useful collateral information which can assist in care planning, even if the patient does not permit the clinician to share information about them. However, if a patient refuses to allow contact, it may not be possible to make this contact. This should be noted in the electronic record.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
Concerns raised 1
Failure to pass on Community Falls Service recommendations to family and social services View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Durham County Council
Work with Community Falls Teams to explore strengthening communication of falls-prevention recommendations to families and social services.
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AI-generated summary
Patricia Heaviside · 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 Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.
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× 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 pass on Community Falls Service recommendations to family and social services
Wider context from the report “(3) Information about the Community Falls Service recommendations was not passed on to the family, or to social services.
” Source location Patricia Heaviside · Prevention of Future Deaths report
Open source report
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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 Work with Community Falls Teams to explore strengthening communication of falls-prevention recommendations to families and social services.
Verbatim wording from the response “We have reviewed this matter and can confirm that we are unable to identify any Council records indicating that the recommendations made by the CDDFT Community Falls Service on 16 August 2023, and again during June 2024, were shared with either Durham County Council or the family by CDDFT Community Falls Team or the Care Home.” Source location Response from Durham County Council
Open published response
30 Jun 2025 Ella Colette La-India DAVID-FONG · Prevention of Future Deaths report West London
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Concerns raised 1
Inadequate information for family and carers on consent, confidentiality and communication when consent is withdrawn View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ella Colette La-India DAVID-FONG · 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
Ella Colette La-India DAVID-FONG was found collapsed outside her home and died in hospital later the same day after taking illicit drugs that resulted in an unintentional overdose. The principal concern was that, when Ella withdrew consent for information to be shared with her family, agencies could not use information held by her family to assist her care. The report also identified inadequate information for families and carers about consent, confidentiality, and how to communicate concerns when consent is withdrawn.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate information for family and carers on consent, confidentiality and communication when consent is withdrawn
Wider context from the report “Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective therapeutic relationships as well as required under the legal framework.
(1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue . The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn . Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing.
” Source location Ella Colette La-India DAVID-FONG · Prevention of Future Deaths report
Open source report
11 Jun 2025 Maureen POWELL · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to keep family informed about wound deterioration View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Red Oaks Care Home
Use a documented Skin Integrity Protocol covering pressure escalation, family updates and duty-of-candour requirements.
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AI-generated summary
Maureen POWELL · 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
Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.
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× 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 keep family informed about wound deterioration
Wider context from the report “6. The family were not kept up to date about deterioration in the wound ;
” Source location Maureen POWELL · Prevention of Future Deaths report
Open source report
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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 Use a documented Skin Integrity Protocol covering pressure escalation, family updates and duty-of-candour requirements.
Verbatim wording from the response “• Following further reflection at the Inquest, a documented Skin Integrity Protocol has now been introduced, formalising the instructions which the nursing team and carers have received through their respective training and providing a single point of reference for them when escalating pressure concerns. The Protocol encompasses guidance on the importance of ensuring that next of kin are kept informed of developments, the requirements of the duty of candour and guidance on the delivery of this, amongst other relevant matters.” Source location Response from Red Oaks Care Home
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.