Recurring concern

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

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First reported 10 Oct 2013•Latest report 14 Jan 2026

Definition

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.

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
21

Distinct published reports

Individual concerns
21

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
24

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.

Department of Health and Social Care7
NHS England2
NHS Greater Manchester Integrated Care Board2
49 Marine Avenue Surgery1
Ayurvedic Professionals Association1
Belmont Health Centre1
Berkshire Healthcare NHS Foundation Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
East London NHS Foundation Trust1
General Medical Council1
General Pharmaceutical Council1
Greater Manchester Health and Social Care Partnership1
Herefordshire and Worcestershire Health and Care NHS Trust1
Kent and Medway Mental Health NHS 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. 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
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Data last updated 7 September 2026