Recurring concern

Failure to reliably identify and communicate individual patient risk factors

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First reported 20 Nov 2013•Latest report 13 Jan 2025

Definition

What this concern includes

Includes failures to identify, assess, document or communicate individual patient risk factors to the clinicians responsible for the patient’s care, including failures to raise known risk factors with consultants and failures of mechanisms intended to ensure relevant clinicians are aware of them.

Not included

  • Excludes generic clinical communication, handover or record-keeping deficiencies where individual patient risk factors are not the material unsafe object.
  • Excludes risk-assessment failures confined to a separately named hazard or pathway, such as VTE, self-harm, mental-health or pregnancy risk, when that named concern provides the more specific supported boundary.
  • Excludes failures to act on risk factors after they have been reliably identified and communicated, unless the identification or communication process is also deficient.
  • Excludes generic organisational risk-assessment criteria or staff competence concerns that are not specifically about identifying or communicating individual patient risk factors.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
18

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Abbey Dale House1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barts Health NHS Trust1
Birmingham Women'S and Children'S NHS Foundation Trust1
Circle Health Group Limited1
Greater Manchester1
Greater Manchester Mental Health NHS Foundation Trust1
Great Western Hospitals NHS Foundation Trust1
NHS England1
Nottingham University Hospitals NHS Trust1
Pennine Care NHS Foundation Trust1
Pentree Lodge1
Royal Devon University Healthcare NHS Foundation Trust1
Royal London Hospital1

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.

  1. North Wales (East and Central)

    AI-generated summary

    Annie Ceinwen Jones · 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

    Annie Ceinwen Jones was admitted to hospital on 1 December 2012 after feeling very poorly and sustaining extensive bruising in a fall from a stand aid. The investigation identified inadequate mobility assessment, an unsafe stand aid, and gaps in staff awareness and competence, although the report states that the incident did not contribute to her death; the inquest conclusion was natural, with bronchopneumonia, volvulus of the sigmoid colon with infarction, and intestinal obstruction recorded as the medical cause of 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 of staff to be aware of patients' mobility limitations

    Wider context from the report

    “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

    Source location

    Annie Ceinwen Jones · 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

    Create an accessible resident mobility summary and person-handling plan for all care staff, including new and agency staff.

    Verbatim wording from the response

    “In order to overcome any communication issues with regards to manual-handling changes, and to provide a point of reference for all staff (including new/agency staff), an updated document has been created to provide a snapshot of each resident's needs, which includes a summary person handling plan, which is readily available to all care staff.”

    Source location

    2013-0306-Response-by-Abbey-Dale-House
    Page 4 · response
    Published 20 November 2013

    Open published response
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Data last updated 7 September 2026