Recurring concern

Unreliable recording and confirmation of specialist clinical advice

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First reported 21 Aug 2014•Latest report 21 Apr 2026

Definition

What this concern includes

Includes failures in the dedicated process for documenting, communicating, confirming or making available specialist clinical advice or treatment instructions to the clinicians or staff responsible for care.

Not included

  • Excludes generic clinical documentation or communication failures where specialist advice or instructions are not the material concern.
  • Excludes failures to seek or obtain specialist advice when the advice-recording, communication or confirmation process is not deficient.
  • Excludes failures involving patient-facing advice, routine handover or non-specialist instructions unless they are explicitly part of communicating or confirming specialist clinical advice.
  • Excludes failures to follow specialist advice after it was reliably recorded and communicated, where the advice-transfer process itself was not unsafe.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
19

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.

Care Quality Commission2
Department of Health and Social Care2
East Kent Hospitals University NHS Foundation Trust2
General Medical Council2
NHS England2
Dartford and Gravesham NHS Trust1
Kent and Medway Mental Health NHS Trust1
Leeds Teaching Hospitals NHS Trust1
NHS Greater Manchester Integrated Care Board1
Parents of Kinga Cieciorska1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Royal College of Physicians1
Royal College of Surgeons of England1
Springfield Home Care Services Limited1

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. Central and South East Kent

    AI-generated summary

    Herbert Chandler · 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

    Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

    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 communicate consultant review findings to the medical on-call team

    Wider context from the report

    “A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”

    Source location

    Herbert Chandler · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026