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. East Sussex

    AI-generated summary

    Trevor Alan MONERVILLE · 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

    Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.

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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

    Inadequate communication about prisoners’ health conditions

    Wider context from the report

    “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing, between the prison staff and family, briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate. Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication. ”

    Source location

    Trevor Alan MONERVILLE · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Implement Regional Multi Professional Complex Case Clinic escalation for the most complex patients.

    Verbatim wording from the response

    “Practice Plus Group operates an integrated healthcare model. Any patients pending transfer back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex Case Clinic (MPCCC) prior to transfer. This allows oversight of all departments within the integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, attended by all clinical leads, and any relevant staff involved in patient care. For individual cases prison partners may be invited to attend and a care plan created with a named coordinator allocated. Practice Plus Group has now implemented a further point of escalation to Regional MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, on occasion, representatives from NHS England.”

    Source location

    Response from Practice Plus Group
    Page 4 · response
    Published 19 January 2024

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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 NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.

    Verbatim wording from the response

    “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 19 January 2024

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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

    Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.

    Verbatim wording from the response

    “As to lack of integration of various systems, this is not an issue that Practice Plus Group can resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned to use SystmOne. As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

    Source location

    Response from Practice Plus Group
    Page 4 · response
    Published 19 January 2024

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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

    Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.

    Verbatim wording from the response

    “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 19 January 2024

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Ms Samantha Jade Shillito · 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

    Ms Samantha Jade Shillito was significantly unwell when admitted to hospital and underwent an ascitic tap procedure that perforated an artery, causing intra-abdominal bleeding. She deteriorated over the following weekend without medical review or further investigations and died on 27 February 2022. Concerns included missed opportunities to respond to her deterioration, inadequate information about the risks of the procedure and shortcomings in 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 communicate the seriousness and potential mortality of a patient's condition to family

    Wider context from the report

    “(4) Ms Shillito’s family were not made aware of the seriousness of her underlying illness. No effective communication was provided to them even on Sunday 27 February to help them appreciate the gravity of her situation. Her husband and her mother informed the inquest that they had not been told that she might die. In consequence, the shock of her death on the evening of Sunday 27 February 2022 was all the greater. It is acknowledged that this concern did not contribute to Ms Shillito’s death, but it underlines the need for compassion and candour when dealing with patients and their families. ”

    Source location

    Ms Samantha Jade Shillito · 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

    Promote and embed compassionate, inclusive communication with patients and their families.

    Verbatim wording from the response

    “I fully recognise the requirement for compassion and candour with patients and families as part of their medical care experience. I am sorry that our communications with Ms Shillito’s family fell below the high standard we strive to achieve, and that they were entitled to expect. The Trust has wholeheartedly embraced the NHS's changed methodology for investigating patient incidents / events through the new national Patient Safety Incident Response Framework (PSIRF), where patients and families have a greater voice and involvement. Aligned with this philosophy, the Trust is actively promoting a more compassionate and inclusive approach by staff/clinicians in all communications with patients and their families.”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 4 · response
    Published 8 December 2023

    Open published response

  3. Manchester South

    AI-generated summary

    Elliott James Harratt · 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

    Elliott James Harratt was born at the family home following his mother's early labour, transferred to Tameside General Hospital, and died there on 29 January 2023 from extreme prematurity. The inquest identified concerns that expectant mothers were not given clear, readily accessible information about sensitising events requiring Anti-D treatment or when to contact maternity triage; this matter did not contribute to Elliott's death.

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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 clearly communicate sensitising events and the required Anti-D action

    Wider context from the report

    “The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum. This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage. ”

    Source location

    Elliott James Harratt · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Highlight the importance of giving RhD-positive mothers appropriate guidance, written information and advice on when to contact services.

    Verbatim wording from the response

    “We will use this event as an opportunity to highlight the importance of ensuring that mothers who do have a D blood type, have the appropriate guidance, written information and understand when to contact services.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 28 July 2023

    Open published response

  4. Milton Keynes

    AI-generated summary

    David WOOD · 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 Wood had recently undergone open heart surgery and was suffering from depression and difficulty sleeping after discharge from hospital. On 22 June 2022, he was found suspended by the neck at his home. A review identified concerns about communication of possible delirium to his GP and wife, discharge planning, and the protocols for discharge following heart surgery.

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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 educate relatives about the possibility of delirium

    Wider context from the report

    “Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”

    Source location

    David WOOD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. West Sussex, Brighton and Hove

    AI-generated summary

    Caroline Victoria Forte · 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

    Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate communication between the ward and family

    Wider context from the report

    “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

    Source location

    Caroline Victoria Forte · Prevention of Future Deaths report
    Page 2 · concerns

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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 provide the family with the Section 17 leave form

    Wider context from the report

    “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

    Source location

    Caroline Victoria Forte · 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

    Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.

    Verbatim wording from the response

    “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 5 May 2023

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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

    Conduct a Trust-wide qualitative audit of inpatient records to assess care-plan completion and meaningful family or carer engagement, then present and monitor findings through the Effectiveness Committee.

    Verbatim wording from the response

    “As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 5 May 2023

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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

    Audit monthly whether families participate in ward reviews or receive follow-up contact about the care plan when unable to attend.

    Verbatim wording from the response

    “As indicated above, safety planning ought to be a collaborative process and I was truly saddened to hear that Caroline's family were left without strategies to support them to minimise Caroline's risks. Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's death. The Matron is overseeing monthly audits to check that family have either participated in ward”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 5 May 2023

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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

    Consider employing a Carers Lead to provide a primary point of contact for family members.

    Verbatim wording from the response

    “reviews, or been contacted after, to be given an update. The ward's aim is to invite a relevant family member to their loved ones' MDT review meetings, so the family member can participate in the review and have an opportunity to give their own views. If they have not been able to attend then a call to the relevant family member is made after the meeting to ensure they are aware of the plan. Additionally, the ward is considering employing a "Carers Lead", who would provide a primary point of contact for all family members. Further, the aforementioned trust-wide care plan and risk assessment auditing includes qualitatively auditing to ensure meaningful, appropriate family/carer engagement, as part of the Trust's ongoing 2023/4 improvement plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 4 · response
    Published 5 May 2023

    Open published response

  6. Norfolk

    AI-generated summary

    Bonnie Rose WEBSTER · 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

    Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

    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 clearly and ensure understanding of the whole situation

    Wider context from the report

    “1. The evidence of Mr and Mrs Webster is they were unaware of the seriousness of the situation. Caesarian Section was discussed but was not advised or recommended at the meeting at 06.50 hours. This was clearly a traumatic meeting and Mr and Mrs Webster were upset which would have impacted on their ability to understand and take in important information. In such a situation clear language and ensuring an understanding of the whole situation is paramount ”

    Source location

    Bonnie Rose WEBSTER · 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

    Share learning from the incident through existing departmental and Trust meetings.

    Verbatim wording from the response

    “In addition to using existing meetings within the department and across the Trust to share the learning in connection with this incident, the senior team has incorporated the learning into the Multi-Disciplinary training day (PROMPT). We believe the MDT approach will support continued improvement in this area, to ensure the whole team is using the same language and feel empowered to use words that are unambiguous. We recognise this is especially important when communicating a potential poor outcome for either the mother or their baby, as was the case in this incident.”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 2022

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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

    Incorporate incident learning into the multidisciplinary PROMPT training day.

    Verbatim wording from the response

    “In addition to using existing meetings within the department and across the Trust to share the learning in connection with this incident, the senior team has incorporated the learning into the Multi-Disciplinary training day (PROMPT). We believe the MDT approach will support continued improvement in this area, to ensure the whole team is using the same language and feel empowered to use words that are unambiguous. We recognise this is especially important when communicating a potential poor outcome for either the mother or their baby, as was the case in this incident.”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 2022

    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

    Deliver team training on unambiguous communication, human factors, informed consent and Montgomery-compliant language through 2023.

    Verbatim wording from the response

    “Our Head of Nursing and Midwifery for the Division of Women and Children, Amanda Price-Davey, will be leading these training sessions through 2023 to ensure she has the opportunity to discuss this with each and every member of the team. This will commence in January 2023. For the part of the training which specifically relates to this case, Mrs Price-Davey is leading the human factors session for a one-hour training session and will discuss the events in detail to evidence how language used can impact on safety. The session will also look at informed consent and the language we use to impart the information needed to ensure Montgomery compliance.”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 2022

    Open published response

  7. South Yorkshire (Western)

    AI-generated summary

    Daniel Lee · 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

    Daniel Lee, aged 22, died by hanging at a disused quarry on 16 September 2021, with the intention to end his life; the inquest concluded that his death was suicide. The report identified concerns about superficial risk assessments, the absence of a key worker, communication with the armed forces and family, and uncertainty about risk-based information sharing.

    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

    Superficiality of communication with the family

    Wider context from the report

    “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust. 5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’. 5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it. 5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns. 5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing. 5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths: • Superficiality of risk assessments • Lack of a key worker approach • Lack of communication with the armed forces, army in this case • Superficiality of communication with the family • Anxiety about appropriate risk sharing ”

    Source location

    Daniel Lee · 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

    Use home-visit progress-note prompts and caseload audits to ensure regular family and carer feedback, involvement and offers of carer assessments.

    Verbatim wording from the response

    “Assurance is currently gained in respect of communication with, and involvement of, families and carers as follows:”

    Source location

    Response from South West Yorkshire Partnership
    Page 5 · response
    Published 25 November 2022

    Open published response

  8. Manchester South

    AI-generated summary

    Susan Mary Regan · 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 Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.

    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 properly communicate care plans with family members

    Wider context from the report

    “1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken. 2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons. ”

    Source location

    Susan Mary Regan · 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

    Adjust multidisciplinary meetings to ensure regular consultant attendance and improve communication and care planning.

    Verbatim wording from the response

    “It is also crucial to note that since the death of Ms Regan, the HTT now has a substantive Consultant Psychiatrist in place. This has brought a greater degree and consistency for both the team and patients using the service. The Multi-Disciplinary meetings (MDM’s) have been adjusted to ensure regular attendance of the consultant. This has allowed a better degree of communication and care planning with mutually agreed goals and actions.”

    Source location

    Response from Pennine Care
    Page 3 · response
    Published 3 October 2022

    Open published response

  9. Manchester South

    AI-generated summary

    Oliver Christopher Lindsay · 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

    Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.

    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 ensure widespread understanding of the risks of fetal growth restriction

    Wider context from the report

    “2. The inquest heard evidence from a number of obstetricians about the very significant risks fetal growth restriction presented to the health of a baby. There was clear evidence that the risks of fetal growth restriction were not widely understood outside experienced obstetric professionals and that greater understanding and clarity of the risks was important in helping all those involved. This was particularly true in relation to parents faced with a sudden change at a difficult time. It was suggested during the inquest that as part of the Saving Babies bundle a FAQ sheet should be developed for parents which set out what fetal growth restriction is ; the risks it presented to a baby at various stages of a pregnancy and the national guidance to reduce risk. ”

    Source location

    Oliver Christopher Lindsay · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Suffolk

    AI-generated summary

    Joshua SAHOTA · 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

    Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.

    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 patient-specific restricted items to families and friends before ward visits

    Wider context from the report

    “relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward. This would be particularly important for a family or friends first visit to the ward. The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances. This makes it clear to all visitors what cannot be taken onto the ward in any circumstances. However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not. From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item. We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room. From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance. Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room. During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession. There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case. I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one. It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends. ”

    Source location

    Joshua SAHOTA · 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

    Improve visitor and service-user communications about the ban on plastic bags through updated letters, external messaging and ward signage.

    Verbatim wording from the response

    “This item is a completely “banned” item across all inpatient units save our rehabilitation unit. Improvements have been made to our external messaging to families and carers on this subject plus a number of safeguards have been put in place to disrupt the passage of restricted items including plastic bags. For example on entering the main Wedgwood reception visitors are asked to show what items they have brought to the unit, if these are within or contain a plastic bag a paper one will be given as a replacement. Likewise for any service user going out on leave, on return they will be given an alternative type of bag either paper or canvas. When advancing to the ward reception there are posters and a “sandwich board” which highlight various pieces of information including restrictions on items coming in to the ward namely plastic bags.”

    Source location

    2021-0301-Response-from-Hellesdon-Hospital_Published
    Page 1 · response
    Published 17 September 2021

    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