Recurring concern

Failure to provide face-to-face clinical assessment when clinically indicated

First to latest report 10 Oct 2013 — 14 Jan 2026

Reports that mention this concern
21
Times this concern has been raised
21
Stated actions linked to this concern
24

What this concern includes

Includes failures in clinical assessment processes where face-to-face assessment is clinically indicated but is omitted, not offered, not required by policy, or replaced by remote contact without an adequate safety threshold; include the anchor and comparable primary-care or community-care assertions.

What is not included
  • Excludes failures limited to telephone mental health assessment, which belong to the separately named mental-health telephone-assessment concern when that is the supported boundary.
  • Excludes remote consultations where the report does not identify a clinically indicated need for face-to-face assessment.
  • Excludes failures in treatment, referral, follow-up or diagnostic testing after an adequate face-to-face assessment has occurred.
  • Excludes generic access, staffing or communication deficiencies unless they directly result in failure to provide clinically indicated face-to-face assessment.

Reports and published responses 21 reports

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

  1. Cambridgeshire (South and West)

    AI-generated summary

    James Edward Mansfield · 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

    James Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

    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 arrange clinical assessment after a telephone report of pain in a high-risk patient

    Wider context from the report

    “(2) When ████████ telephoned the surgery, complaining of Mr Mansfield’s pain, strong pain killers were prescribed but he was not seen despite a long history of lung and chest complaints, multiple rib fractures and treatment with warfarin. ”

    Source location

    James Edward Mansfield · 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.

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Data last updated 7 September 2026