Recurring concern

Unsafe management of barriers to necessary medical investigations

First to latest report 6 Nov 2019 — 8 Jul 2026

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures in the dedicated process for identifying and addressing barriers to necessary medical investigations, including pursuing suitable alternative investigations and exploring or providing support options that could enable patient engagement.

What is not included
  • Excludes generic failures to offer alternative services, treatments or medications where the issue is not a necessary medical investigation.
  • Excludes ordinary refusal of care or treatment where no investigation-specific barrier or alternative is identified.
  • Excludes failures to interpret investigation results or act on findings after a suitable investigation has been completed.
  • Excludes generic communication, capacity-assessment or staffing deficiencies unless they directly impair the safe management of barriers to a necessary medical investigation.

Reports and published responses 2 reports

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

  1. Sunderland

    AI-generated summary

    Marie Bell · 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

    Marie Bell underwent surgery for a bowel obstruction on 25 July 2025. An unrecognised small-bowel perforation developed into faecal peritonitis, and she died in hospital on 29 July 2025. The report also raises concern that being unable to undergo colonoscopy was treated as declining all investigations, rather than prompting consideration of alternative methods.

    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 explore alternative investigations when an initial investigation is unsuitable

    Wider context from the report

    “Where one means of investigation is not suitable for a patient due to comorbidities or conditions this does not mean that the patient is declining all investigations and an alternative should be explored. ”

    Source location

    Marie Bell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    Hazel Maureen Lewis · 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

    Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.

    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 explore and advise on available support options for engagement with medical investigations or care

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”

    Source location

    Hazel Maureen Lewis · Prevention of Future Deaths report
    Page 2 · 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