Recurring concern

Unreliable recording and confirmation of specialist clinical advice

First to latest report 21 Aug 2014 — 21 Apr 2026

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
19

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.

What is 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 and published responses 11 reports

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

  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

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