Recurring concern

Failure to adapt healthcare communication for neurodivergent patients and parents

First to latest report 30 Mar 2026 — 27 May 2026

Reports that mention this concern: 2
Times this concern has been raised: 6
Stated actions linked to this concern: 12

What this concern includes

Includes failures in healthcare assessment, care or treatment processes to recognise neurodivergent communication needs and adapt communication, information presentation, questioning, prompts or interpretation so that clinically important information, agreement and care requirements are accurately elicited and understood.

What is not included

Excludes generic communication, staff-training or documentation deficiencies where neurodivergence is not a material part of the asserted unsafe condition.
Excludes failures in diagnosis, treatment, service access or care coordination where adapted healthcare communication is not the deficient control.
Excludes general family support or information provision unrelated to communicating with or interpreting information from neurodivergent patients or parents.
Excludes autism-specific placement, mental-health treatment or reasonable-adjustment concerns where communication adaptation is not the shared unsafe condition.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Essex Partnership University NHS Foundation Trust1

George Eliot Hospital NHS Trust1

NHS England1

Royal College of General Practitioners1

Reports and published responses 2 reports

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

27 May2026
Essex
Concerns raised2
1. Failure to adapt communication and information presentation to neurodivergent patients
2. Lack of staff training in autism and communication with neurodivergent people with learning disabilities
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Essex Partnership University NHS Foundation Trust
Stated actions 5
1. Essex Partnership University NHS Foundation Trust
  Maintain inpatient operating-model guidance on reasonable adjustments and support for adults with learning disabilities and autistic adults.
2. Essex Partnership University NHS Foundation Trust
  Provide sensory rooms and individual sensory boxes across Linden and Crystal Centres for patients requiring neurodiversity-related adjustments.
3. Essex Partnership University NHS Foundation Trust
  Provide neurodiversity-specific care plans with MDT involvement and access to Psychology and the Trust autism specialist.
1. Essex Partnership University NHS Foundation Trust
  Require all staff to complete national mandatory Oliver McGowan training.
2. Essex Partnership University NHS Foundation Trust
  Deliver inpatient autism training developed from the National Autism Training Programme framework.
AI-generated summary

Abbigail Louise SMITH · 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

Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

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 adapt communication and information presentation to neurodivergent patients
Wider context from the report
“7. Staff at were not trained in Autism or how to communicate with Abbi as a neurodivergent person with a learning disability. Expert evidence was that there was insufficient exploration of how this impacted specifically on Abbi and how to communicate with her and how information should have been presented to her about her diagnosis, care and treatment. The evidence of some later training was not considered sufficient. ”
Source location
Abbigail Louise SMITH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of staff training in autism and communication with neurodivergent people with learning disabilities
Wider context from the report
“7. Staff at were not trained in Autism or how to communicate with Abbi as a neurodivergent person with a learning disability. Expert evidence was that there was insufficient exploration of how this impacted specifically on Abbi and how to communicate with her and how information should have been presented to her about her diagnosis, care and treatment. The evidence of some later training was not considered sufficient. ”
Source location
Abbigail Louise SMITH · Prevention of Future Deaths report
Page 4 · 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
Maintain inpatient operating-model guidance on reasonable adjustments and support for adults with learning disabilities and autistic adults.

Verbatim wording from the response
“A number of steps have been taken to address Neurodiversity support within the Inpatient setting. There is a section on page 41/42 in the EPUT Therapeutic Acute Inpatient Operating Model for Adults and Older Adults’ (2024) with the heading ‘Adults with a learning disability and autistic adults’ which includes ‘reasonable adjustments’ and NHSE Guidance references, which includes key actions which need to take place for adults with a learning disability and autistic adults.”

Source location
Response from Essex Partnership University NHS Trust
Page 6 · response
Published 13 August 2026
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
Provide sensory rooms and individual sensory boxes across Linden and Crystal Centres for patients requiring neurodiversity-related adjustments.

Verbatim wording from the response
“A range of different initiates are available on different wards, within the Linden Centre there are now Sensory Rooms within three of the wards (including Galleywood). The sensory rooms have dimmed lights, sensory equipment such as sensory chairs, rocking chairs, black out blinds, projectors, a water bed, and weighted blankets. These rooms have been developed with the help of Occupational Therapists, Psychology and the patients themselves and are available to use 24/7.”

Source location
Response from Essex Partnership University NHS Trust
Page 6 · response
Published 13 August 2026
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
Provide neurodiversity-specific care plans with MDT involvement and access to Psychology and the Trust autism specialist.

Verbatim wording from the response
“Patients with an identified Neurodiversity need / diagnosis will have a specified care plan suited to their needs working alongside the MDT. Staff are also clear to seek the support of Psychology when a need is identified as well as the Trust- Autism Specialist, Dr Dakin.”

Source location
Response from Essex Partnership University NHS Trust
Page 6 · response
Published 13 August 2026
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
Require all staff to complete national mandatory Oliver McGowan training.

Verbatim wording from the response
“All staff are now required to take part in the national mandatory Oliver McGowan training which was legislated on 1st July 2022, and rolled out at EPUT in 2023.”

Source location
Response from Essex Partnership University NHS Trust
Page 5 · response
Published 13 August 2026
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
Deliver inpatient autism training developed from the National Autism Training Programme framework.

Verbatim wording from the response
“From a psychology perspective, a number of staff within the Trust have undertaken the National Autism Training Programme which has a specific focus on inpatient settings. The in-patient Psychology team have used this framework to develop a one day training around working with Autistic individuals for inpatient staff. This has been in operation for approximately 2 years at the Trust.”

Source location
Response from Essex Partnership University NHS Trust
Page 7 · response
Published 13 August 2026
Open published response
30 Mar2026
Warwickshire
Concerns raised4
1. Lack of practical mechanisms for communicating with neurodivergent parents
2. Lack of structured local support for interpreting neurodivergent parental communication
3. Lack of practical mechanisms for adapting assessment of neurodivergent children
1. Lack of structured local prompts for recognising neurodivergent symptom expression
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

George Eliot Hospital NHS Trust
Stated actions 7
1. George Eliot Hospital NHS Trust
  Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.
2. George Eliot Hospital NHS Trust
  Develop and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.
3. George Eliot Hospital NHS Trust
  Establish neurodivergent champion roles across GEH and SWFT with a dedicated training programme.
1. George Eliot Hospital NHS Trust
  Amend the paediatric casualty card to record children’s communication, sensory or behavioural needs.
2. George Eliot Hospital NHS Trust
  Provide specialist Play Specialist support to improve communication and reduce anxiety for neurodivergent children.
3. George Eliot Hospital NHS Trust
  Implement the FLACC behavioural pain assessment tool within the Clinical Assessment Unit.
4. George Eliot Hospital NHS Trust
  Implement the approved formal escalation pathway and supporting materials for neurodivergent patients.
Respondent positions 1
1. George Eliot Hospital NHS Trust
  Practical mechanisms in GIRFT guidance fall outside the Trust’s direct remit; the Trust will comply with any enhanced guidance GIRFT issues.
  Outside remit
AI-generated summary

Ethan Michael Hanson · 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

Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.

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
Lack of practical mechanisms for communicating with neurodivergent parents
Wider context from the report
“GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of structured local support for interpreting neurodivergent parental communication
Wider context from the report
“Local processes provide no structured support for neurodivergent children or parents Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of practical mechanisms for adapting assessment of neurodivergent children
Wider context from the report
“GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of structured local prompts for recognising neurodivergent symptom expression
Wider context from the report
“Local processes provide no structured support for neurodivergent children or parents Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · 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
Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.

Verbatim wording from the response
“• The learning from this case is being built into a simulation programme. The upcoming CAU simulation sessions will involve a wider multi-disciplinary group and will include scenarios around abdominal pain, including neurodivergent children, to support better recognition, communication, and escalation. These sessions are held monthly.”

Source location
Response from George Eliot Hospital NHS Trust
Page 3 · response
Published 25 June 2026
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 and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.

Verbatim wording from the response
“• The Trust’s Communications Team is developing a formal communications plan, in partnership with the Paediatric Neurodiversity & Learning Disability Lead, to increase awareness and utilisation of Hospital Passports and “All About Me” tools. This will include a public-facing campaign, commencing in July 2026 and continuing thereafter.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Establish neurodivergent champion roles across GEH and SWFT with a dedicated training programme.

Verbatim wording from the response
“• A neurodivergent champion role is being established across GEH and SWFT, supported by a dedicated training programme. These roles will act as advocates for neurodivergent patients and their families, with implementation scheduled from July 2026.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Amend the paediatric casualty card to record children’s communication, sensory or behavioural needs.

Verbatim wording from the response
“• The paediatric casualty card is currently being amended to include whether the parent/carer has any potential neurodiverse implications which may affect communication. This has been discussed with the Paediatric Neurodiversity & Learning Disability Lead for South Warwickshire NHS University Foundation Trust (SWFT). This has identified that the question to be placed on the casualty card should be “does this child have any communication, sensory or”

Source location
Response from George Eliot Hospital NHS Trust
Page 4 · response
Published 25 June 2026
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
Provide specialist Play Specialist support to improve communication and reduce anxiety for neurodivergent children.

Verbatim wording from the response
“• The Trust has a Play Specialist in post, providing specialist support to reduce anxiety and enhance communication for neurodivergent children through appropriate tools and techniques.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Implement the FLACC behavioural pain assessment tool within the Clinical Assessment Unit.

Verbatim wording from the response
“• The FLACC (Face, Legs, Activity, Cry, Consolability) behavioural pain assessment tool is being implemented within CAU to support more consistent and appropriate pain assessment, with full implementation anticipated by the end of June 2026.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Implement the approved formal escalation pathway and supporting materials for neurodivergent patients.

Verbatim wording from the response
“• A formal escalation pathway has been developed to support staff in managing neurodivergent patients, promoting increased clinical curiosity and consideration of atypical presentations. Supporting materials, including a flowchart and handbook were approved on 21 May 2026 and implementation will commence.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Practical mechanisms in GIRFT guidance fall outside the Trust’s direct remit; the Trust will comply with any enhanced guidance GIRFT issues.

Verbatim wording from the response
“The Trust acknowledges the concerns raised regarding the absence of practical mechanisms within the GIRFT guidance to support assessment and communication with neurodivergent children and their families. However, this matter falls outside the Trust’s direct remit. GIRFT has been made aware of these considerations through receipt of the Coroner’s Regulation 28 Report to Prevent Future Deaths. The Trust will, however, ensure full compliance with any enhanced or updated guidance issued by GIRFT in response to these findings.”

Source location
Response from George Eliot Hospital NHS Trust
Page 4 · response
Published 25 June 2026
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to adapt communication and information presentation to neurodivergent patients

Lack of staff training in autism and communication with neurodivergent people with learning disabilities

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised4

Lack of practical mechanisms for communicating with neurodivergent parents

Lack of structured local support for interpreting neurodivergent parental communication

Lack of practical mechanisms for adapting assessment of neurodivergent children

Lack of structured local prompts for recognising neurodivergent symptom expression

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 5

Stated actions 7

Respondent positions 1