Recurring concern

Unreliable communication of care-review meeting outcomes

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First reported 29 Mar 2016•Latest report 2 May 2025

Definition

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.

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.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
2

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.

Essex Partnership University NHS Foundation Trust1
NHS England1
NHS Greater Manchester Integrated Care Board1
The Children's Trust1

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. Inner West London

    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
  2. Manchester South

    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
  3. Essex

    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
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Data last updated 7 September 2026