Recurring concern

Failure to reliably identify and communicate individual patient risk factors

First to latest report 20 Nov 2013 — 13 Jan 2025

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
18

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  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

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