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. Milton Keynes

    AI-generated summary

    Iain Neil MACINNES · 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

    Iain Neil MACINNES was found hanging at his home in Milton Keynes on 17 January 2019, after his mental health had deteriorated during December 2018. The report identified concerns that his family were not informed about his deterioration or transfer to the Acute Home Treatment Team, and that there was a failure to recognise the extent of his deterioration, resulting in lost opportunities for hospital admission.

    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 keep patients’ families informed of significant changes in care

    Wider context from the report

    “During the course of the evidence it became apparent that, despite the fact that the deceased had indicated that he wanted information to be shared with his family and for them to be involved in his care, they were not informed that his condition had deteriorated and that he had been transferred to the Home Treatment Team although it was widely accepted that it is important that the family are involved in a patients treatment and care. The process for recording details of the family and for keeping them informed needs to be reviewed by the trust and proposals for reform considered. ”

    Source location

    Iain Neil MACINNES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester City

    AI-generated summary

    Alistair Patrick McDonald · 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

    Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.

    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 communication with the patient and family for review when mental state deteriorates

    Wider context from the report

    “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted 2. The lack of a specific plan for referrals to other services which proved unsuccessful 3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist. 4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates 5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress 6. Recognising that some patients will only make partial disclosure of their true symptomology and history. 7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this 8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this. ”

    Source location

    Alistair Patrick McDonald · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The assessment and communication arrangements were considered reasonable and proportionate, so no further action was identified.

    Verbatim wording from the response

    “The Choice assessment was attended by the mother of Mr Alastair McDonald, and the detailed assessment notes that her views were taken into consideration in line with the overall formulation of the assessment and outcome.”

    Source location

    2019-0257-Worcestershire-Health-and-Care-NHS-Trust
    Page 2 · response
    Published 6 September 2019

    Open published response

  3. Manchester South

    AI-generated summary

    Hannah Dolly Kaur Bharaj · 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

    Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

    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 of discharge planning to share risk information with GPs and families

    Wider context from the report

    “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective. Key information was not shared with the GP or the family particularly when care moved back to the family; ”

    Source location

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate the change in risk level when patients leave a secure environment

    Wider context from the report

    “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family; ”

    Source location

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. London (East)

    AI-generated summary

    Sophie Holman · 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

    Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.

    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 inform the family of the child’s risk of poor asthma outcomes

    Wider context from the report

    “2) There was: a. No coordinated record of these occasions b. No analysis of the frequency or circumstances of these events c. No analysis of the underlying chronic asthma condition d. No appreciation of the risk factors for future attacks and death due to asthma in this child e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma ”

    Source location

    Sophie Holman · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    Emmett Alexander Gillah · 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

    Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.

    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 with families about treatment decisions and discharge

    Wider context from the report

    “(3) More broadly to those issues raised at (1) & (2), communication arrangements in existence within KMPT between staff engaged in the care of a patient and patient families who may be directly affected by decisions relating to the patient’s treatment, were inadequate e.g. Mr Gillah’s family were not consulted in relation to the decision to discharge Mr Gillah or received any formal communication in relation to the circumstances of Mr Gillah’s discharge. ”

    Source location

    Emmett Alexander Gillah · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate communication of post-discharge treatment access information

    Wider context from the report

    “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge. This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests. No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect. ”

    Source location

    Emmett Alexander Gillah · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  6. Staffordshire South

    AI-generated summary

    Derek Reginald Smith · 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

    Derek Reginald Smith, who was bedbound and unable to manage his care needs, died at home on 21 December 2017 from aspiration pneumonia. He had developed a severe pressure sore, and the report raised concerns about limited communication between district nurses, family members and possibly carers, as well as the availability of nursing records and delays in treatment decisions.

    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 communication between district nursing teams, family members and other agencies involved

    Wider context from the report

    “It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well). There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved. ”

    Source location

    Derek Reginald Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Somerset

    AI-generated summary

    Robin Damien Richards · 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

    Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

    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 of communication with family and between Trust staff

    Wider context from the report

    “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards ”

    Source location

    Robin Damien Richards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Black Country

    AI-generated summary

    Mrs Christine Withers · 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

    Mrs Christine Withers, a 72-year-old woman with small cell carcinoma of the lung, was admitted with low potassium levels and died on 17 November 2017 after her condition deteriorated rapidly. Concerns identified during the inquest included that repeat blood tests were not performed to measure potassium levels despite a recommendation to do so, and inadequate communication by nursing staff with her family about her decline.

    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 nursing communication with families expressing concerns about patient deterioration

    Wider context from the report

    “2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers. ”

    Source location

    Mrs Christine Withers · 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

    Complete in-house palliative care competencies for Ward C4 staff, including communication with patients, families and carers.

    Verbatim wording from the response

    “In response to this sad event all the staff within Ward C4 are working with our palliative care champion to complete the in-house palliative care competencies which comprehensively covers communication with patients, families and carers.”

    Source location

    2018-0127-Response-by-Dudley-Group-NHS-Trust
    Page 2 · response
    Published 1 July 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Records documented multiple family conversations, and staff considered communication effective, despite the family appearing dissatisfied with some answers.

    Verbatim wording from the response

    “2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers.”

    Source location

    2018-0127-Response-by-Dudley-Group-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    Open published response

  9. Sunderland

    AI-generated summary

    Patricia Ann Heslop · 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 Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

    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 regular information about care

    Wider context from the report

    “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including: • the unusual and regular use of a wheelchair; • the rocking manoeuvre by two members of staff to get Patricia from her chair; • the fact that two members of staff would walk with Patricia. These matters were not recorded, as they ought to have been, nor were the family informed, as they should have been. It is important that family members have confidence in the provision of care to a loved one and have regular information provided to them. ”

    Source location

    Patricia Ann Heslop · 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

    Coach shift and Household leaders to obtain and regularly verify family contact details through the Resident of the Day process.

    Verbatim wording from the response

    “2.9 HC-One has also undertaken additional work to ensure that shift and Household leaders have been instructed to obtain as many details of family contacts as possible and ensure that family contacts are reviewed regularly. This is being managed through individual coaching sessions by the Area Team on leading and managing and effective completion of the Resident of the Day process, which prompts the person completing to review and seek confirmation from family members or carers that details held are correct and that any specific parameters are accurate.”

    Source location

    2018-0102-Response-by-HC-One
    Page 5 · response
    Published 17 June 2018

    Open published response

  10. Inner North London

    AI-generated summary

    Freddie Oliver DOBINSON-EVANS · 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

    Freddie Dobinson-Evans had undiagnosed Dravet syndrome and died from causes recorded as post-cardiac arrest syndrome and Dravet syndrome. A genetic test report was communicated to his father as “absolutely normal”, although Freddie had a pathogenic SCN1A gene mutation; the report identified the potential for significant consequences for another child.

    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 genetic test results accurately

    Wider context from the report

    “Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”

    Source location

    Freddie Oliver DOBINSON-EVANS · 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

    Ensure effective ongoing communication between the paediatric neurology team and clinical scientists to clarify genetic test results.

    Verbatim wording from the response

    “6. I will ensure that myself and the paediatric neurology team members keep effective communication with the Clinical scientists shall there remain in clarities.”

    Source location

    2018-0078-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 16 June 2018

    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