Recurring concern

Unreliable inter-specialty communication for complex patient care

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First reported 27 Sep 2013•Latest report 22 Dec 2025

Definition

What this concern includes

Includes failures of dedicated communication arrangements between clinical specialties involved in the same patient's care, including absent or ineffective formal frameworks, unclear communication routes, poor exchange of plans and actions, and unreliable communication in complex or dynamically changing cases, including across NHS Trusts.

Not included

Excludes generic communication or information-sharing failures where no inter-specialty clinical-care context is identified.
Excludes failures confined to a single specialty's internal communication, documentation or clinical decision-making.
Excludes inter-agency coordination concerns involving non-clinical agencies or services unless the assertion specifically concerns communication between clinical specialties.
Excludes failures in a separately named pathway, such as radiology coordination, clinical handover or a condition-specific referral system, where that named process provides the more specific supported boundary.

Reports: 17
Individual concerns: 18
Date range: 2013–2025
Stated actions: 34

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

Manchester University NHS Foundation Trust3

Barts Health NHS Trust2

NHS England2

Aneurin Bevan University LHB1

Association Of British Neurologists1

Bournemouth, Christchurch and Poole Council1

Bristol NHS Foundation Trust1

Care Quality Commission1

College of Policing1

Dorset County Council1

Dorset Healthcare University NHS Foundation Trust1

Dorset Police1

King'S College Hospital NHS Foundation Trust1

Lincolnshire County Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Jan2022
East London
Concerns raised1
1. Failure to use targeted factual communication between surgical and anaesthetic teams during surgery
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Surekha Pandharinath Shivalkar · 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 Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

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 use targeted factual communication between surgical and anaesthetic teams during surgery
Wider context from the report
“2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen. ”
Source location
Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report
Page 3 · concerns
Open source report
7 Oct2020
Manchester South
Concerns raised1
1. Failure to manage differences between haematology and neurosurgical recommendations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alison Jean Shirley Jeanes · 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

Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.

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 manage differences between haematology and neurosurgical recommendations
Wider context from the report
“3. The inquest heard that haematology advice on the day of admission was to reduce her INR. This advice was reconfirmed by the neuro surgeons the following day. There were differences in the recommendations and it was not entirely clear how that difference was being managed. In any event despite repeated attempts with Vitamin K Mrs Jeanes INR remained above the target. Further advice from the haematologist was not sought until 26th March some 9 days after her admission. It was unclear why that delay had occurred as the notes suggested it had been recognised that advice should have been sought previously but this had not been followed up. There was no evidence before the inquest of what system was in place or who would take responsibility for follow up in such a situation. ”
Source location
Alison Jean Shirley Jeanes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2020
Lincolnshire
Concerns raised1
1. Lack of interface between senior or experienced providers for complex cases
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Attend Dual Diagnosis interface meetings and contribute to community release plans with mental-health and wider partner services.
  Stated by WithYouStated completed
2. Action
  Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
  Stated by Lincolnshire County CouncilStated in progress
3. Action
  Implement robust communication, information-sharing and aligned clinical pathways with We Are With You.
  Stated by Lincolnshire Partnership NHS Foundation TrustStated planned
1. Action
  Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
  Stated by Lincolnshire Partnership NHS Foundation TrustStated planned
2. Action
  Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
  Stated by Lincolnshire Partnership NHS Foundation TrustStated planned
AI-generated summary

Toby Peter Edward Nieland · 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

Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

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 interface between senior or experienced providers for complex cases
Wider context from the report
“9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to: a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases; b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases; c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care; ”
Source location
Toby Peter Edward Nieland · Prevention of Future Deaths report
Page 5 · 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
Attend Dual Diagnosis interface meetings and contribute to community release plans with mental-health and wider partner services.

Verbatim wording from the response
“• We have enhanced our reciprocal training to LPFT and regularly attend interface meetings for Dual Diagnosis patients and ensure we have input into community release plans. Additionally, we provide opportunities for staff from LPFT, the Police, Probation and Children's Services as well as housing providers. to spend time within our teams to further their experience of substance misuse interventions. We have commenced delivery of group work interventions within the Mental Health units in Lincoln (Discovery House and PHC) for those with a dual diagnosis.”

Source location
2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
Page 2 · response
Published 26 October 2020
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
Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.

Verbatim wording from the response
“i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust”

Source location
2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Page 2 · response
Published 26 October 2020
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 robust communication, information-sharing and aligned clinical pathways with We Are With You.

Verbatim wording from the response
“The Trust and ‘We Are With You’ (as Addaction is now called) will work together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways and protocols, with the aim to make collaborative working between the two organisations standard practice. The Trust confirms this is part of its work plan over the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division.”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020
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
Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.

Verbatim wording from the response
“Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020
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
Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.

Verbatim wording from the response
“We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 7 · response
Published 26 October 2020
Open published response
20 Dec2019
Inner North London
Concerns raised1
1. Failure to ensure communication between interventional radiology and hepatology specialists
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
  Stated by Barts Health NHS TrustStated completed
Respondent positions 1
1. Position
  Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Keith HILL · 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

Keith Hill was admitted with biliary sepsis and underwent a liver biopsy, after which he developed bleeding requiring surgery and later suffered bowel haemorrhage. The report identified concerns about communication between specialists, inadequate medical records, and insufficient support and scrutiny around the prescription and dispensing of micafungin.

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 communication between interventional radiology and hepatology specialists
Wider context from the report
“1. When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and a more accurate record of the decision making. ”
Source location
Keith HILL · 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
Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.

Verbatim wording from the response
“This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.”

Source location
2019-0446-Response-from-Barts-NHS-Trust-R
Page 1 · response
Published 6 January 2020
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
Further discussions with the referring team at the procedure stage would not have changed the procedure performed.

Verbatim wording from the response
“This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.”

Source location
2019-0446-Response-from-Barts-NHS-Trust-R
Page 1 · response
Published 6 January 2020
Open published response
16 Jul2018
Manchester City
Concerns raised1
1. Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sheila Winifred Ridgway · 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

Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report
“1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously ”
Source location
Sheila Winifred Ridgway · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Nov2016
Manchester West
Concerns raised1
1. Failure of communication between specialist teams caring for patients under shared care
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Discuss shared-care communication concerns at the Trust’s Clinical Advisory Board.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Develop a shared-care guidance note reminding clinical staff of their communication responsibilities.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progress
3. Action
  Distribute the approved shared-care guidance to clinical staff and upload it to the Trust’s policy library.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated planned
1. Action
  Monitor the shared-care actions through the Quality and Safety Committee with updates every two months.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated planned
Respondent positions 3
1. Position
  The absence of direct communication between surgical and cardiology teams did not contribute to the deceased’s death.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustDisputes the concern
1. Position
  Daily reviews and documented management plans provided sufficient shared-care communication, so direct discussion was not indicated.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  Much shared-care communication responsibility rests with clinicians’ obligations under the GMC’s Good Medical Practice guidance.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustRedirects responsibility
AI-generated summary

Patrick Richard Steer · 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

Patrick Richard Steer was admitted with abdominal pain, found to have a cancerous bowel tumour, and underwent surgery. He subsequently suffered a myocardial infarction and developed a right sub hepatic abscess before his condition deteriorated and he died. The principal concern was poor communication between the Surgical and Coronary Care teams when patients were under shared care, which could affect treatment.

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 between specialist teams caring for patients under shared care
Wider context from the report
“I have concerns with regard to the following: i. That in circumstances where a patient is under the care of both the Surgical and Coronary Care teams, communication between the Doctors of those teams does not work well and could affect the treatment a patient receives which could lead to a future death. ”
Source location
Patrick Richard Steer · 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
Discuss shared-care communication concerns at the Trust’s Clinical Advisory Board.

Verbatim wording from the response
“The concerns you raised in respect of shared care were also discussed at the Trust’s Clinical Advisory Board (CAB) on 7 December 2016 by senior members of the Medical Directors and is attended by senior representatives from the various clinical areas.”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 1 · response
Published 19 February 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
Develop a shared-care guidance note reminding clinical staff of their communication responsibilities.

Verbatim wording from the response
“However it is accepted that there are occasions when shared care is not as easy, particularly when important changes to a daily basis. This can be challenging in terms of communication between teams, and it is then crucial that teams agree some fundamental principles such as ceilings of care, and who communicates directly with the patient and families.”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 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
Distribute the approved shared-care guidance to clinical staff and upload it to the Trust’s policy library.

Verbatim wording from the response
“In that respect the ████████ Responsible Officer, ████████ was asked to draft a guidance note in respect of shared care that could be circulated within the Trust to remind clinical staff of their responsibilities. I enclose a draft guidance note that is being discussed at the next Clinical Advisory Board on 18 January 2017.”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 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
Monitor the shared-care actions through the Quality and Safety Committee with updates every two months.

Verbatim wording from the response
“Continued Monitoring”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 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 absence of direct communication between surgical and cardiology teams did not contribute to the deceased’s death.

Verbatim wording from the response
“Having reviewed the clinical records, ████████ is satisfied that the absence of direct communication between the two clinical teams did not contribute to the deceased’s demise; it appears that both teams were satisfied with each other’s management plans and documentation, and therefore there was no indication to have direct discussion.”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 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
Daily reviews and documented management plans provided sufficient shared-care communication, so direct discussion was not indicated.

Verbatim wording from the response
“I however confirmed that Mr Ster received daily reviews from both teams (surgical and cardiac), however no direct communication took place between the two teams. The documentation to indicate that either team had encountered any difficulties in attempting to communicate with the other. Both teams were able to review and comment on each others’ documented management plans.”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 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
Much shared-care communication responsibility rests with clinicians’ obligations under the GMC’s Good Medical Practice guidance.

Verbatim wording from the response
“Following discussions at the Trust’s Clinical Advisory Board, it was agreed that much of the requirement for communication within shared care falls under the remit of the GMC’s (General Medical Council) Good Medical Practice which clinicians are required to adhere to. Under section 11, in respect of communication within and between the GMC states as follows:”

Source location
2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 19 February 2017
Open published response
27 Sep2013
Avon
Concerns raised1
1. Inadequate communication between the neonatal intensive care and cardiac units
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
2. Action
  Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
3. Action
  Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.
  Stated by Bristol NHS Foundation TrustStated planned
AI-generated summary

Rose Jean COLES · 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

Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

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 neonatal intensive care and cardiac units
Wider context from the report
“Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”
Source location
Rose Jean COLES · 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
Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

Verbatim wording from the response
“Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
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
Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

Verbatim wording from the response
“| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
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
Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

Verbatim wording from the response
“| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to use targeted factual communication between surgical and anaesthetic teams during surgery

Concerns raised1

Failure to manage differences between haematology and neurosurgical recommendations

Concerns raised1

Lack of interface between senior or experienced providers for complex cases

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to ensure communication between interventional radiology and hepatology specialists

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments

Concerns raised1

Failure of communication between specialist teams caring for patients under shared care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Inadequate communication between the neonatal intensive care and cardiac units

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 5

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 3

Actions described in response 3