Recurring concern

Failure to provide timely clinical care

First to latest report 28 Aug 2013 — 14 Jan 2026

Reports that mention this concern
17
Times this concern has been raised
17
Stated actions linked to this concern
22

What this concern includes

Includes delays or omissions in providing clinically required patient care, medical review or treatment where the delay can permit deterioration, worsen risk or reduce available treatment options, including the anchor's similar delays in patient care and delayed necessary treatment after recognition of a life-threatening condition.

What is not included
  • Excludes delays confined to a separately named clinical pathway, condition, service or operational process where that named concern provides the more specific supported boundary.
  • Excludes delays in ambulance attendance, hospital admission, specialist referral, diagnostic investigations or discharge when those processes are the specific unsafe condition rather than delayed clinical care generally.
  • Excludes failures to recognise deterioration where no delay in providing clinical care is identified.
  • Excludes delays caused solely by patient choice or clinically justified prioritisation where care remained within a safe timeframe.

Reports and published responses 17 reports

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

  1. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · 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

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    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

    Delays in arranging urgent tests and treatment

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. East London

    AI-generated summary

    Mrs Catherine Dinnen · 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

    Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

    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

    Delays in securing timely medical review

    Wider context from the report

    “2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”

    Source location

    Mrs Catherine Dinnen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Leicester City and South Leicestershire

    AI-generated summary

    George Boulton · 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

    George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

    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

    Delays in patient care allowing further deterioration and loss of treatment options

    Wider context from the report

    “4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse; while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options. ”

    Source location

    George Boulton · 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

    Communicate emergency-response guidance to lead commissioners for dissemination to GPs and Bed Bureau services.

    Verbatim wording from the response

    “As this implementation will take some considerable amount of time, as an immediate action we will communicate with our lead commissioners to disseminate the following message to all GP’s and Bed Bureau.”

    Source location

    2015-0255-Responses
    Page 2 · response
    Published 6 July 2015

    Open published response

    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

    Develop guidance on practical design principles for faster, safer urgent and emergency care pathways.

    Verbatim wording from the response

    “In terms of national work, in January 2013 NHS England launched a review of urgent and emergency care services in England. The new urgent and emergency care system will ensure that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise. We have developed guidance which summarises practical design principles that local health communities should adopt to deliver faster, better, safer care. This will help front line providers and commissioners improve the flow of patients through the urgent and emergency pathway, increasing the availability of resources.”

    Source location

    2015-0255-Responses
    Page 7 · response
    Published 6 July 2015

    Open published response

  4. London (East)

    AI-generated summary

    Mr Pether · 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

    Mr Pether was admitted after a fall that caused a right femur peri-prosthetic fracture, with a pre-existing infection and an open fracture increasing the risk of infection. Transfer for complex surgery was delayed, and records identified no focused medical or nursing checks of limb viability between 11 and 20 December 2012. The wound was found to be infected and necrotic on 20 December; despite surgery, amputation and intensive care, Mr Pether deteriorated and died from left ventricular failure after developing multi-organ failure.

    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 conduct detailed assessment and re-consult treatment options during clinical deterioration

    Wider context from the report

    “3. By the 19 December 2012, there was a raised CRP and evidence of an acute kidney injury. It is certainly arguable that a more detailed assessment of the patient at that time and a re-consultation of options by the orthopaedic team should have taken place at that time. ”

    Source location

    Mr Pether · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Plymouth, Torbay and South Devon

    AI-generated summary

    Leslie Edmund Harding (Lez) · 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

    Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

    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 ensure prompt treatment of suspected life-threatening conditions

    Wider context from the report

    “1. ████████ took no action during the period from 18 – 28 September 2013. Patients with a suspected life-threatening condition (Pulmonary Embolus) must be promptly treated. The system for ensuring that the treatment is provided must be robust. That is particularly the case where it is already known that the patient suffers from an underlying condition that makes him prone to the particular life-threatening event. ”

    Source location

    Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
    Page 3 · 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

    Audit all patients receiving acute or recurrent pulmonary-embolism treatment for similar omissions.

    Verbatim wording from the response

    “2) Having reviewed this case, I am undertaking an audit of all people receiving treatment for pulmonary emboli whether acute or recurrent to ensure that no similar omissions have occurred.”

    Source location

    2014-0169-Response-by-Oakside-Surgery
    Page 2 · response
    Published 8 April 2014

    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

    A patient with mental capacity could refuse hospital admission and treatment despite the risk of later harm.

    Verbatim wording from the response

    “I did note that Mr Harding was judged to have mental capacity and that he appeared to have made an informed decision in the days leading up to the 18th September 2013 on more than one occasion not to be then admitted to hospital and received what I can consider to be the appropriate treatment. He appears to have made this decision in the knowledge that the outcome could have been fatal.”

    Source location

    2014-0169-Response-by-Oakside-Surgery
    Page 1 · response
    Published 8 April 2014

    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

    Pulmonary embolism should not be treated in the community without hospital investigations because anticoagulation could cause equally serious harm.

    Verbatim wording from the response

    “I also feel that it would have been inappropriate for ████████ to have treated Mr Harding as if he had a pulmonary embolism within the community without appropriately investigating it with investigations which were only available within a hospital setting. If he had done so, this would”

    Source location

    2014-0169-Response-by-Oakside-Surgery
    Page 1 · response
    Published 8 April 2014

    Open published response

  6. Manchester South

    AI-generated summary

    Barbara White · 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

    Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

    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 provide further clinical consideration after requested tests

    Wider context from the report

    “4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations. ”

    Source location

    Barbara White · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Terrance O’Connell · 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

    Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.

    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 provide timely clinical assessment of a patient's condition

    Wider context from the report

    “(3) Mr O’Connell did not have any clinical assessment of his condition for 2 days until his admission to hospital ”

    Source location

    Terrance O’Connell · Prevention of Future Deaths report
    Page 1 · 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

    Implement a clinical-assessment policy requiring transfer to A&E when health professionals cannot attend within one hour.

    Verbatim wording from the response

    “Notwithstanding this, the Monkstone House policy has now been changed with regard to clinical assessment. The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 2 · response
    Published 28 August 2013

    Open published response

    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

    Hold senior-staff meetings to reinforce seeking medical advice and ensuring clients are seen by a professional when concerns arise.

    Verbatim wording from the response

    “3 Meetings have been held with senior staff and if there are any concerns regarding clients, staff are to seek medical advice, ensuring that all clients are seen by a professional. If, for whatever reason clients cannot be seen at Monkstone House and if out of hours GP and nurses will not attend, Monkstone House will send the client to A&E department for assessment as soon as practical.”

    Source location

    2013-0218-Response-by-Gabbandco
    Page 3 · response
    Published 28 August 2013

    Open published response

    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

    Develop a clear out-of-hours escalation process for resolving disputed clinical issues.

    Verbatim wording from the response

    “Issue identified: Lack of process in place to escalate the issue re the dispute between the two clinicians.”

    Source location

    2013-0218-Response-by-University-Health-Board
    Page 10 · response
    Published 28 August 2013

    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

    The district nursing assessment was appropriate because the catheter was draining freely; the patient required medical rather than nursing assessment.

    Verbatim wording from the response

    “The district nursing staff made an appropriate assessment on the information supplied by the care home i.e. that the catheter was draining freely, and therefore the cause of the pain would not have been a blocked catheter.”

    Source location

    2013-0218-Response-by-University-Health-Board
    Page 7 · response
    Published 28 August 2013

    Open published response

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