Recurring concern

Unreliable confidentiality arrangements for sharing safety-critical welfare information

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First reported 5 May 2013•Latest report 15 Jan 2020

Definition

What this concern includes

Includes failures in confidentiality guidance, decision-making or operational arrangements that prevent or delay receipt, acceptance or sharing of safety-critical welfare information between callers, families, healthcare services and emergency responders, where the information is needed to assess or protect a person at risk.

Not included

  • Excludes ordinary confidentiality or consent concerns with no identified impact on safety-critical welfare information.
  • Excludes generic communication, referral or information-sharing failures where confidentiality uncertainty is not the cause of the unsafe condition.
  • Excludes clinical assessment, treatment or emergency response failures after the relevant welfare information has been reliably received and shared.
  • Excludes disclosure processes involving courts, regulators, coroners or other recipients unless the asserted concern is the same safety-critical welfare-information confidentiality arrangement.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2013–2020

First to latest report issue date

Stated actions
5

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 Care1
Greater Manchester Mental Health NHS Foundation Trust1
Greater Manchester Police1
HM Prison Service1
NHS England1
NHS Greater Manchester Integrated Care Board1
North West Ambulance Service NHS Trust1
Pennine Care NHS Foundation Trust1
Samaritans1

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. Manchester West

    AI-generated summary

    Daniel Jeffrey Moran · 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

    Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

    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 recognise when patient confidentiality should be breached to notify family or friends about patient safety or welfare concerns

    Wider context from the report

    “1. Staff were unaware of the situations where it was appropriate to breach patient confidentiality and notify family or friends, when concerns arose regarding patient safety/welfare. ”

    Source location

    Daniel Jeffrey Moran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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 Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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 accepting and passing on welfare concerns because of confidentiality uncertainty

    Wider context from the report

    “The Court heard the calls between NK and NWAS. Advice was provided to NK that a concern for welfare could not be taken by them due to a potential “breach of confidentiality”. This led to a further delay in this concern for welfare call being passed to NWAS. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Central Hampshire

    AI-generated summary

    Haydn James Burton · 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

    Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.

    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 Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk

    Wider context from the report

    “(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT. ”

    Source location

    Haydn James Burton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Winchester will not add an exception to Listener confidentiality because national confidentiality arrangements are considered necessary to preserve prisoners’ trust.

    Verbatim wording from the response

    “As the Samaritans have set out in their separate response to your report, the principle of total confidentiality is central to their work, and applies equally to the work of Listeners. This is reflected in the national partnership agreement between NOMS and the Samaritans that governs the operation of the Listener scheme, and the NOMS safer custody policy set out in PSI 64/2011. In the light of this it is not appropriate for Winchester to adopt a different policy on this point. Without the assurance of confidentiality, prisoners may not feel able to approach Listeners and talk freely in an atmosphere of total trust. Any change to this approach may lead to a reduction in the number of prisoners accepting this vital source of support and sharing their concerns.”

    Source location

    2016-0346-Response-by-NOMS
    Page 2 · response
    Published 4 October 2016

    Open published response
  4. South Yorkshire (Eastern)

    AI-generated summary

    Colin Tyson · 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

    Colin Tyson attempted suicide by carbon monoxide poisoning on 6 August 2014 and was resuscitated. On 11 August 2014, he stepped in front of a high-speed train and died from the impact. The principal concern was that GPs’ interpretation of patient confidentiality could prevent concerned family members from passing on pertinent information about vulnerable people at risk of suicide.

    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

    GPs' interpretation of patient confidentiality preventing concerned family members from passing pertinent information about vulnerable persons at potential risk of suicide

    Wider context from the report

    “(1) Concern regarding GPs interpretation of patient confidentiality preventing concerned family members passing pertinent information regarding vulnerable persons who are potentially at risk of suicide. ”

    Source location

    Colin Tyson · 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

    Develop an advice sheet for GP practices on responding to third-party concerns and information-sharing requests.

    Verbatim wording from the response

    “We have worked together to develop an advice sheet for GP practices on the appropriate response when third parties raise concerns or request sharing of information about a patient registered at the practice. As you rightly noted this is an area which many practices do not feel confident about and hence there is a risk that relevant and important information does not reach the patient’s GP.”

    Source location

    2015-0080-Response-by-NHS-England
    Page 1 · response
    Published 4 March 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

    Disseminate the advice sheet to GPs through Local Medical Committees in every district.

    Verbatim wording from the response

    “I attach a copy of this advice sheet for your information. It will be shared with all GP practices in Wakefield by the CCG and across Yorkshire and the Humber by the safeguarding network. In addition we will disseminate this information to all GPs in conjunction with the Local Medical Committees in every district. The advice contained within the advice sheet will also form part of the training that is offered to practices in relation to the safeguarding of adults and children.”

    Source location

    2015-0080-Response-by-NHS-England
    Page 1 · response
    Published 4 March 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

    Include the advice sheet's guidance in safeguarding training offered to practices.

    Verbatim wording from the response

    “I attach a copy of this advice sheet for your information. It will be shared with all GP practices in Wakefield by the CCG and across Yorkshire and the Humber by the safeguarding network. In addition we will disseminate this information to all GPs in conjunction with the Local Medical Committees in every district. The advice contained within the advice sheet will also form part of the training that is offered to practices in relation to the safeguarding of adults and children.”

    Source location

    2015-0080-Response-by-NHS-England
    Page 1 · response
    Published 4 March 2015

    Open published response
  5. North London

    AI-generated summary

    Roshen Abbas Ladak-Ebrahim · 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

    Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

    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

    Confusion about confidentiality when providing safety supervision for patients at risk of self-harm

    Wider context from the report

    “Consideration to be given to giving guidance to health care professionals on the steps that should be taken to ensure that a patient is kept safe by those looking after the patient. In particular informing those looking after a patient that the patient should not be left alone where there is a concern that the patient is at risk of harming themselves. Evidence heard at the inquest suggested that there was some confusion over whether this advice would breach a patient's confidentiality. ”

    Source location

    Roshen Abbas Ladak-Ebrahim · 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

    Publish a consensus statement promoting information sharing to help prevent suicide, within the relevant law.

    Verbatim wording from the response

    “Turning to confidentiality, there are clearly times when health care professionals, in dealing with a person at risk of suicide, may need to inform the family about aspects of risk to help keep the patient safe. I agree it is crucial that we address any confusion about how information can be shared. That is why the Department of Health is already working with Royal Colleges and professional organisations to agree a consensus statement designed to promote greater sharing of information with the aim of preventing suicide, within the context of the relevant law. We published this on 17 January at:”

    Source location

    2013-0287-Response-by-Department-of-Health
    Page 2 · response
    Published 5 November 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

    Publish supplementary guidance clarifying when confidential information may be disclosed in the public interest.

    Verbatim wording from the response

    “In addition, the Department of Health published supplementary guidance to the NHS Confidentiality Code of Practice (November 2010, Ref 13912) on disclosing confidential information when there is a public interest justification to do so and makes clear to healthcare professionals when it is appropriate to disclose personal information.”

    Source location

    2013-0287-Response-by-Department-of-Health
    Page 3 · response
    Published 5 November 2013

    Open published response
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Data last updated 7 September 2026