Recurring concern

Failure to maintain auditable records of safety-critical telephone communications and actions

First to latest report 19 Dec 2014 — 27 Oct 2023

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures to record, preserve, link or otherwise make safety-critical telephone calls, handovers, advice, callback requests and resulting actions independently auditable, including emergency 999 or 111 calls and callback actions where auditability is needed for safety assurance or learning.

What is not included
  • Excludes ordinary telephone communications with no identified safety, clinical, emergency or welfare significance.
  • Excludes failures to act on a communication when the communication and resulting action record were reliably auditable.
  • Excludes general clinical-record, handover or incident-reporting deficiencies where the specific telephone communication or resulting action is not the object of the auditability failure.
  • Excludes telephone-call recording or preservation failures that do not have a safety-critical communication, decision or resulting action context.

Reports and published responses 2 reports

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

  1. Inner West London

    AI-generated summary

    Kai TAKAGI · 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

    Kai Takagi attended Chelsea and Westminster Hospital on 11 June 2021 with severe stomach pain and left before an abnormal blood result, suggestive of acute pancreatitis, was received. The hospital planned to contact him but did not do so, and he was found dead at home on 14 June 2021; the stated medical cause of death was acute peritonitis from a perforated gastric ulcer. Concerns included inadequate tracking and follow-up of patients who leave with outstanding abnormal test results, reliance on oral handover, and incomplete implementation of a clinician-led review system.

    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 independently auditable callback handover

    Wider context from the report

    “(3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has. ”

    Source location

    Kai TAKAGI · 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

    Trusts are responsible for procedures following national guidance and for responding on handover arrangements and clinician-led review of abnormal blood results.

    Verbatim wording from the response

    “It is the responsibility of Trusts to ensure that they have the necessary procedures and arrangements in place to follow national guidance. It will also be for the Trust to comment on your concerns surrounding their handover arrangements and the clinician led review into abnormal blood results. NHS England notes that you have also addressed your Report to Chelsea and Westminster Hospital. We will carefully consider their response to you which we have asked to be sighted on.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 11 December 2023

    Open published response

  2. Inner West London

    AI-generated summary

    Ms Samia Yasmin Shara · 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

    Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.

    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 auditability of long and complex 999 and 111 calls

    Wider context from the report

    “(1) That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance process. ”

    Source location

    Ms Samia Yasmin Shara · Prevention of Future Deaths report
    Page 2 · 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