Recurring concern

Unreliable communication of care-review meeting outcomes

First to latest report 29 Mar 2016 — 2 May 2025

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 2

What this concern includes

Includes failures to record, confirm, communicate or hand over outcomes, decisions and agreed actions from care-planning or care-review meetings to affected people, carers or staff responsible for ongoing care.

What is not included

Excludes generic communication failures that are not tied to care-planning or care-review meeting outcomes and actions.
Excludes failures in the substantive quality of a meeting decision where communication of the outcome operated reliably.
Excludes routine meeting administration and meeting minutes unrelated to patient, resident or service-user care.
Excludes failures to implement an outcome after it was reliably communicated, unless the communication process itself was also deficient.

Trends

Reports over time

Reports mentioning this concern, 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.

Essex Partnership University NHS Foundation Trust1

NHS England1

NHS Greater Manchester Integrated Care Board1

The Children's Trust1

Reports and published responses 3 reports

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

2 May2025
Inner West London
Concerns raised1
1. Inadequate communication of planning and review meeting matters and actions to care providers
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

The Children's Trust
Stated actions 1
1. The Children's Trust
  Use standardised, structured shift handovers with tools, relevant meeting updates, and regular audits.
AI-generated summary

Raihana Oluwamidalo Awolaja · 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

Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.

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 planning and review meeting matters and actions to care providers
Wider context from the report
“7. That the systems of communication between those attending planning and review meetings and those providing care to the residents are inadequate, such that matters raised at these meetings and any actions agreed to address them are insufficiently communicated to those providing care to the residents. ”
Source location
Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report
Page 4 · 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
Use standardised, structured shift handovers with tools, relevant meeting updates, and regular audits.

Verbatim wording from the response
“• Improved Handover Protocols: Shift handovers now follow a standardised, structured protocol supported by clear tools to ensure comprehensive transfer of information between teams, reducing the risk of important details being missed.”

Source location
Response from The Children’s Trust
Page 1 · response
Published 19 May 2025
Open published response
10 Feb2023
Manchester South
Concerns raised1
1. Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS England
NHS Greater Manchester Integrated Care Board
Stated actions 1
1. NHS Greater Manchester Integrated Care Board
  Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.
Respondent positions 1
1. NHS England
  Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.
  Redirects responsibility
AI-generated summary

Sandra Adina Lomax · 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

Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

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 the MDT to effectively communicate agreed actions and recommendations for individual patients
Wider context from the report
“4. This was compounded by the fact that the inquest heard evidence that the MDT did not have a system of effective communication of agreed actions and recommendations for individual patients discussed at the MDT. As a consequence local clinicians were unsighted as to the recommended way forward. The inquest was told that an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes. ”
Source location
Sandra Adina Lomax · 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
Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.

Verbatim wording from the response
“Recognising the challenges in relation to MDT working, the Greater Manchester Cancer Alliance have an improvement programme in place in relation to MDT reform:”

Source location
Response from Greater Manchester Integrated Care
Page 3 · response
Published 24 February 2023
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
Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.

Verbatim wording from the response
“GM are the appropriate organisation to respond to your concerns around GM staffing issues and ineffective communication between the MDT. I have been sighted on their response and welcome the Greater Manchester Cancer Alliance improvement programme for MDT reform. I also note that they will be sharing learning from Sandra’s death across the Greater Manchester System.”

Source location
Response from NHS England
Page 2 · response
Published 24 February 2023
Open published response
29 Mar2016
Essex
Concerns raised2
1. Failure to sign off review meeting outcomes in writing
2. Failure to clearly communicate review meeting outcomes to the affected person
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dorota Agnieszka Kijowska · 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

Dorota Agnieszka Kijowska was found hanging at Gosfield ward on 23 March 2015 after returning from weekend leave and expressing threats to harm herself. The report identified concerns that the review outcome was not documented or clearly communicated to her, alongside a jury finding of failures to provide a safe environment and ineffective communication.

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 sign off review meeting outcomes in writing
Wider context from the report
“The outcome of the review meeting was not signed off in writing by those in attendance (Consultant psychiatrist, middle grade doctor, review nurse) and clearly communicated to Dorota ”
Source location
Dorota Agnieszka Kijowska · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 clearly communicate review meeting outcomes to the affected person
Wider context from the report
“The outcome of the review meeting was not signed off in writing by those in attendance (Consultant psychiatrist, middle grade doctor, review nurse) and clearly communicated to Dorota ”
Source location
Dorota Agnieszka Kijowska · 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.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Inadequate communication of planning and review meeting matters and actions to care providers

Linked response

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

Concerns raised1

Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients

Linked responses

Stated actions 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 raised2

Failure to sign off review meeting outcomes in writing

Failure to clearly communicate review meeting outcomes to the affected person

Stated actions 1

Stated actions 1

Respondent positions 1