Recurring concern

Failure to communicate safety-critical care information effectively between care providers and families

First to latest report 7 Jan 2014 — 1 Jun 2026

Reports that mention this concern
70
Times this concern has been raised
74
Stated actions linked to this concern
94

What this concern includes

Includes failures in provider-to-family or family-to-provider communication where the information concerns patient safety, clinical risks, care plans, deterioration, leave arrangements, incidents, complaints or other matters directly relevant to safe care.

What is not included
  • Excludes communication failures solely between professionals, services or departments when families are not a relevant party.
  • Excludes generic failures of documentation, staffing, training or policy compliance unless they directly constitute or prevent communication of safety-critical information to or from families.
  • Excludes routine information provision or dissatisfaction that is not tied to a meaningful public-safety concern.
  • Excludes communication with patients, students, prisoners or other beneficiaries where families are not materially involved.

Reports and published responses 70 reports

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

  1. Oxfordshire

    AI-generated summary

    Cain Alex River Donald · 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

    Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

    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

    Insufficient communication with family members about discharge risks and support needs

    Wider context from the report

    “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

    Source location

    Cain Alex River Donald · 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 family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.

    Verbatim wording from the response

    “More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 17 June 2025

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Esther Jane Lancaster Byrne · 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

    Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.

    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 diagnosis, treatment options, rationale and discharge plans with family representatives

    Wider context from the report

    “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. ”

    Source location

    Esther Jane Lancaster Byrne · 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

    Allocate a multidisciplinary team member on ward rounds to update families about all aspects of patient care.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 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

    Conduct regular retrospective clinical-record audits to monitor compliance with family communication standards.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

    Open published response

  3. East London

    AI-generated summary

    George Kenneth Fraser · 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

    George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.

    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 maintain meaningful family contact about concerning loss of contact

    Wider context from the report

    “(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024. ”

    Source location

    George Kenneth Fraser · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.

    Verbatim wording from the response

    “Missed Appointments Procedure”

    Source location

    Response from North East London Foundation Trust
    Page 4 · response
    Published 29 May 2025

    Open published response

  4. Inner West London

    AI-generated summary

    Raihana Oluwamidalo Awolaja · 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

    Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.

    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

    Insufficient communication with commissioning authorities and next of kin about care and supervision risks

    Wider context from the report

    “3. That TCT do not sufficiently communicate with the commissioning LA nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left Raihana alone. This in turn leaves vulnerable residents at risk, as the named social workers and possibly the commissioning authority nor the next of kin will be aware of potential increased risks to the vulnerable child. This matter also goes to matter 2 above. ”

    Source location

    Raihana Oluwamidalo Awolaja · 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

    Implement communication protocols for promptly and transparently sharing serious care or safeguarding concerns with families and local authorities.

    Verbatim wording from the response

    “• New Communication Protocols: We have implemented new communication protocols to ensure that all serious care or safeguarding concerns are promptly and transparently shared with the child’s family and the relevant local authority. This is done in accordance with the Patient Safety Incident Response Framework (PSIRF) and our updated incident management policy and procedures.”

    Source location

    Response from The Children’s Trust
    Page 3 · response
    Published 19 May 2025

    Open published response

  5. Suffolk

    AI-generated summary

    Denise Ellen Johnson · 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

    Denise Ellen Johnson was admitted to hospital with abdominal pain and jaundice, underwent ERCP with stent insertion, and subsequently developed severe acute necrotising pancreatitis. Despite intensive supportive care, drainage, antibiotics and other treatment, she died on 24 November 2022; the inquest recorded multi-organ failure, severe E. coli septicaemia, pancreatic necrosis and ischaemic bowel perforation. The principal concerns were delayed notification and formal review of serious ERCP complications, inadequate communication with the next of kin and family about management plans, and unclear consultant cover during unexpected leave, each identified as posing a significant risk to patient safety.

    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 regular explanations and discussions with NOK/family about ongoing management plans and treatment options for inpatients with serious surgical issues

    Wider context from the report

    “Not having regular explanations and discussions with NOK/family by the responsible Consultant concerning ongoing management plans and treatment options for inpatients with serious surgical issues and, ”

    Source location

    Denise Ellen Johnson · 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 allocation of a named consultant to patients to improve access for patients and families discussing treatment plans.

    Verbatim wording from the response

    “The Trust is also implementing changes to ensure a named Consultant is allocated to patients, which will provide greater accessibility for patients and families to discuss treatment plans.”

    Source location

    Response from East Suffolk and North Essex Foundation Trust
    Page 2 · response
    Published 17 January 2025

    Open published response

  6. North Yorkshire and York

    AI-generated summary

    Janet Kathleen SEDDON · 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

    Janet Kathleen Seddon underwent surgery after a CT scan was re-reviewed and found to show abdominal pathology that had not been identified in the initial report. She deteriorated with signs of sepsis and died in hospital on 9 February 2023. Concerns included the delay in identifying the pathology, the absence of a proper assessment of harm, and delays in disclosing the reporting error to her family and the Coroner.

    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

    Delays in clear disclosure of reporting errors to families and the Coroner

    Wider context from the report

    “1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death. 2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death. 3. My concerns relate to – a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error; b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error; c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner; d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed; e) the potential risk of death to others in the event of a recurrence of any of the above. ”

    Source location

    Janet Kathleen SEDDON · 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 Incident Management Policy and Compassionate Engagement and Duty of Candour Policy.

    Verbatim wording from the response

    “Following the introduction of the new PSIRF framework the Trust updated the Incident Management Policy and Procedures (March 2024) and its Duty of Candour Policy, now called Compassionate Engagement and Duty of Candour Policy (June 2024) which are available should you wish to have sight of them.”

    Source location

    Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
    Page 1 · response
    Published 15 October 2024

    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

    Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.

    Verbatim wording from the response

    “The Trust Radiology Duty of Candour Standard Operating Procedure (SOP) (available should you wish to have sight of this) describes how discrepancies are assessed to establish if radiological errors have occurred and how these are then disclosed to clinicians to evaluate degree of harm and inform duty of candour conversations if required. This SOP is in line with, and applies, national Royal College guidance to our processes. It was last revised in July 2024, before this inquest, and that update included specifying the one-week turnaround timeframe for reporters responding to a candour panel, improving efficiency from the Radiology side of the process, and a two-week response timeframe for treating clinicians to respond to Radiology letters disclosing confirmed radiological errors and requesting feedback on the degree of harm.”

    Source location

    Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
    Page 2 · response
    Published 15 October 2024

    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

    Submit further Radiology SOP updates for Radiology Directorate review and Care Group Board approval.

    Verbatim wording from the response

    “Further updates to the SOP have been developed to clarify that the receiving treating clinician’s Care Group governance team should be copied into the initial correspondence to the clinician, and if required escalation for feedback on level of harm will take place with the Cancer, Specialist and Support Services (CSCS) Care Group Director contacting the Director of the respective Care Group. This will ensure a more timely outcome regarding level of harm and in turn a duty of candour conversation with patient and/or family with the treating clinician, supported by a radiologist. These updates will be submitted to the next Radiology Directorate Meeting and on approval to CSCS Care Group Board for virtual agreement on 12/12/24.”

    Source location

    Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
    Page 2 · response
    Published 15 October 2024

    Open published response

  7. 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

  8. South Yorkshire (Eastern)

    AI-generated summary

    Robert Fuller · 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

    Robert Fuller was admitted to Doncaster Royal Infirmary with increased confusion and later suffered an assault by another patient, causing him to fall and sustain a traumatic brain bleed. He subsequently deteriorated and died on 22 July 2022; the inquest concluded that he died from natural causes, with pathology confirming that the assault-related injuries did not cause or contribute to his death. Concerns included poor record keeping, inadequate communication with the family after the incident, and the lack of a system for agency staff to access and communicate reminders, policies and procedures.

    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 and inaccurate communication with families following incidents

    Wider context from the report

    “2. This poor record keeping also lead to poor/inaccurate communication following the incident with the family. ”

    Source location

    Robert Fuller · 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

    Recruit and appoint two dedicated Family Liaison Officers for patient-safety investigations and serious complaints.

    Verbatim wording from the response

    “As part of our PSIRF transition and in line with the framework, we are appointing to specific and dedicated roles to be known as Family Liaison Officers (FLO). Family Liaison Officers support patients and families through the process of an investigation into a patient safety incident, or a serious complaint against a service provided by the Trust. The Trust is actively recruiting two professionals and hope to have individuals in post by the autumn. I would like to assure you our teams have also received training in line with the PSIRF training framework on engaging and involving patients, families and staff following a patient safety incident. We have also reminded staff of the importance of effective communication and recording of conversations with patients and or their families following a learning from patient safety event.”

    Source location

    Response from DBTH
    Page 3 · response
    Published 4 April 2024

    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

    Train staff on engaging and involving families after patient-safety incidents and reinforce communication-recording requirements.

    Verbatim wording from the response

    “As part of our PSIRF transition and in line with the framework, we are appointing to specific and dedicated roles to be known as Family Liaison Officers (FLO). Family Liaison Officers support patients and families through the process of an investigation into a patient safety incident, or a serious complaint against a service provided by the Trust. The Trust is actively recruiting two professionals and hope to have individuals in post by the autumn. I would like to assure you our teams have also received training in line with the PSIRF training framework on engaging and involving patients, families and staff following a patient safety incident. We have also reminded staff of the importance of effective communication and recording of conversations with patients and or their families following a learning from patient safety event.”

    Source location

    Response from DBTH
    Page 3 · response
    Published 4 April 2024

    Open published response

  9. Manchester South

    AI-generated summary

    Susan Wendy Bracegirdle · 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

    Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a communication strategy supporting joint working and family involvement in pressure-ulcer care

    Wider context from the report

    “2. There was no communication strategy in place as a consequence of an approach that did not promote team /joint working. The inquest heard that as a consequence the family were unsighted on the condition of Mrs Bracegirdle until shortly before her admission to hospital. This meant that the family could not support the work to reduce the risk of the pressure ulcers deteriorating further and were not able to be a proactive about the care she was receiving increasing the risk of her pressure ulcers deteriorating ”

    Source location

    Susan Wendy Bracegirdle · 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 an information leaflet explaining how families can contact District Nursing for pressure-area-care advice.

    Verbatim wording from the response

    “In undertaking this review there was evidence of verbal communication with the care home staff and written notes within the communication book at the care home. However, an information leaflet will be developed to promote communication.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 12 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include joint-working Quality Statements in the service’s next assessment and follow up actions addressing previously identified communication shortfalls.

    Verbatim wording from the response

    “At our last inspection of Stable Steps Care Centre on 8 and 19 June 2023 we found that improvements were needed to ensure communication worked effectively within the home. Feedback from people living at the home and their families was mixed with some people feeling staff were responsive to their needs, whilst others gave examples of where they felt there had been delays in receiving treatment. Families also told us communication between healthcare services and the home could be difficult, staff were not always able to identify deterioration in people and that liaison and referrals with external services could be improved.”

    Source location

    Response from Care Quality Commission
    Page 5 · response
    Published 12 February 2024

    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

    Follow up the registered manager’s investigation into failures to keep families informed and seek assurance that resulting actions mitigate communication risks.

    Verbatim wording from the response

    “We would expect, as parties to general reviews of care whilst at the home, a person’s family to be involved and informed, with the consent of the individual, regarding their care, treatment and progress. We note that the registered manager in her statement, advised that she had apologised to the family for the failure to keep them informed regarding Mrs Bracegirdle’s pressure ulcers and that she had committed to investigating this shortfall. We will follow up on the outcome of the investigation to seek assurance that any actions arising from the investigation will mitigate further risks that families are not kept informed where appropriate within acceptable timeframes.”

    Source location

    Response from Care Quality Commission
    Page 6 · response
    Published 12 February 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 care home provider is responsible for keeping family members updated about residents’ health, including pressure ulcer management and nursing advice.

    Verbatim wording from the response

    “The care home provider would be expected to keep family members updated in relation to all aspects of a resident’s health and wellbeing as a matter of course, using the information from the communications book, and from direct conversations with the attending district nurses. In the event of further questions from the family then it would be expected for the care home staff to liaise with the attending team to obtain information to address those questions. This would include information about pressure ulcer management and any advice from community colleagues (District Nursing Team) or the TVN Team.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 12 February 2024

    Open published response

  10. Teesside and Hartlepool

    AI-generated summary

    Kate Elizabeth O’Donnell · 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

    Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

    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 families with deterioration warning signs and actions at discharge

    Wider context from the report

    “10. The family were not provided with information upon discharge as to what signs to look out for and what steps to take if Kate was to deteriorate. ”

    Source location

    Kate Elizabeth O’Donnell · 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

    Develop and provide patients and carers with a postoperative sepsis-awareness information card.

    Verbatim wording from the response

    “A conversation should have taken place to advise Kate’s parents of the signs and symptoms of sepsis however on this occasion this did not happen. One of the actions completed as part of the Serious Incident investigation was to develop a sepsis awareness information card which is now given to patients/carers post operatively.”

    Source location

    Response from South Tees Hospitals
    Page 5 · response
    Published 25 January 2024

    Open published response

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

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Data last updated 7 September 2026