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. Surrey

    AI-generated summary

    Ronald Arthur Farrington · 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

    Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to inform family about developed pressure sores

    Wider context from the report

    “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores, nor that the CQC were conducting any enquiries. ”

    Source location

    Ronald Arthur Farrington · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Tomas Kelly · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source location

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

    Open source report

  3. Inner North London

    AI-generated summary

    Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate expected illness progression and clear action plans to families

    Wider context from the report

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

    Source location

    Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and consult service users and carers on a written discharge care plan template.

    Verbatim wording from the response

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

    Source location

    response-Pinto
    Page 2 · response
    Published 5 April 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

    response-Pinto
    Page 2 · response
    Published 5 April 2017

    Open published response

  4. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 during the ACCT process

    Wider context from the report

    “(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent, yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment. It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same. ”

    Source location

    JACK OLIVER PORTLAND · 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 the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.

    Verbatim wording from the response

    “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.

    Verbatim wording from the response

    “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    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 prison can only prompt family contact, and effective involvement depends on the prisoner’s consent.

    Verbatim wording from the response

    “Family contact The value of family involvement for prisoners, and the significant resettlement opportunities that contact with family members presents, are recognised. However, the prison can only prompt this contact (and it could only be effective) with the consent of the prisoner.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

  5. Black Country

    AI-generated summary

    Mr Ronald Compson · 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

    Mr Ronald Compson, who had Parkinson’s disease, was admitted to hospital after confusion and drowsiness and later sustained an unwitnessed fall with a head injury. He subsequently became unresponsive and died from a subdural haematoma; concerns included failure to notify a doctor, vomiting episodes with poor record keeping, and poor communication with his family about the fall.

    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 communication with the family about falls

    Wider context from the report

    “3. There was poor communication to the family about the initial fall. ”

    Source location

    Mr Ronald Compson · 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 a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.

    Verbatim wording from the response

    “The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.”

    Source location

    2018-0030-Response-by-Dudley-Group-NHS-Trust
    Page 1 · response
    Published 8 June 2018

    Open published response

  6. Cornwall and Isles of Scilly

    AI-generated summary

    Danny Sweet · 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

    Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.

    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 share relevant self-harm concerns with family or friends reporting deterioration

    Wider context from the report

    “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating. I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality. ”

    Source location

    Danny Sweet · 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

    Hold a Learning from Experience meeting with relevant clinical staff to consider developing a care pathway, engaging family and friends, and producing an action plan.

    Verbatim wording from the response

    “It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by ████████ Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.”

    Source location

    2016-0275-Response-by-Cornwall-NHS-Trust
    Page 2 · response
    Published 29 July 2016

    Open published response

  7. Leicester City and South Leicestershire

    AI-generated summary

    William Abel · 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

    William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

    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 of professional concerns and safe-keeping expectations to family members

    Wider context from the report

    “2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night. ”

    Source location

    William Abel · 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

    Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.

    Verbatim wording from the response

    “Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    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

    Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.

    Verbatim wording from the response

    “The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it. This will also be given to a carer, friend or family member if they are present at the assessment and the patient has consented to their involvement. We will implement this change for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    Open published response

  8. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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

    Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

    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 adequately with patients and families

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · 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

    Recruit a Clinical Nurse Practice Educator based on Twineham ward to support staff, including communication training.

    Verbatim wording from the response

    “a) the recruitment of a new Clinical Nurse Practice Educator based on Twineham ward. This postholder is able to assist staff with a range of issues, including providing training on all aspects of communication (written and verbal)”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response

  9. South Yorkshire (Eastern)

    AI-generated summary

    James Savo · 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

    James Savo had a longstanding history of depression and died by hanging on 3 December 2013, four days after discharge from inpatient treatment. The concerns identified were insufficient communication with family and carers, inadequate consideration of family concerns and the timing of home-treatment input during discharge planning, and variable understanding and possible inadequacy of the early discharge pathway. The report also identified a lack of effective auditing to ensure communication systems were followed.

    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 routinely follow communication systems between families and carers

    Wider context from the report

    “(1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed. As this communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the communication, the nature of it and who has primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being followed. ”

    Source location

    James Savo · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Barbara Joan Harrison · 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

    Barbara Joan Harrison was admitted on 5 February 2015 for surgery after worsening swallowing and regurgitation symptoms, and subsequently developed significant surgical emphysema and undetected mediastinitis. Concerns included potentially harmful postoperative physiotherapy, failed attempts to site an endotracheal tube due in part to unavailable fibre-optic equipment, inadequate lighting during critical surgery, distress caused to her family, and delayed recognition of swelling around her neck and face.

    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 appropriate communication and privacy around critical incidents

    Wider context from the report

    “4. Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital. As they were waiting, they heard one of the porters shout out “we have got a cardiac arrest in theatre.” This caused them extreme distress and alarm.” ”

    Source location

    Barbara Joan Harrison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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