Recurring concern

Unreliable coordination and scheduling of district nursing visits

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First reported 17 Jun 2014•Latest report 22 Feb 2021

Definition

What this concern includes

Includes failures in the dedicated district nursing visit-scheduling and coordination process, including incorrect dates, missed or inadequately tracked visits, and failure to coordinate district nurse attendance with required carers or other essential support when this affects delivery of the planned nursing care.

Not included

Excludes district nursing assessment, wound care, referral, staffing-capacity and clinical-treatment failures where visit scheduling or coordination is not the shared unsafe condition.
Excludes generic appointment, communication or care-coordination failures outside district nursing visits.
Excludes delays or omissions caused solely by a patient's refusal or unavailability when the district nursing scheduling and coordination process operated reliably.
Excludes failures occurring after a district nursing visit was correctly scheduled and coordinated when the remaining issue is the quality of care delivered during the visit.

Reports: 3
Individual concerns: 4
Date range: 2014–2021
Stated actions: 2

Reports 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.

Blackpool Teaching Hospitals NHS Foundation Trust1

Medway Community Healthcare C.I.C.1

North Shore Surgery1

The Whittington Hospital1

Whittington Health NHS Trust1

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.

22 Feb2021
Inner North London
Concerns raised1
1. Failure to routinely coordinate district nurse and carer visits
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Discuss care coordination with the family and caring nurse, agree the plan, and document it in the electronic care plan.
  Stated by Whittington Health NHS TrustStated planned
2. Action
  Monitor family care-coordination arrangements through senior-nurse review, case-note audits and caseload reviews.
  Stated by Whittington Health NHS TrustStated planned
AI-generated summary

Cecilia EDWARDS · 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

Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.

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 routinely coordinate district nurse and carer visits
Wider context from the report
“3. The district nurses who visited Cecilia Edwards needed the assistance of the two carers to turn her and attend to all her nursing needs, but sometimes when they visited there were no carers present and so the nursing care given was incomplete. The carers attended at set hours four times a day, and so it seems that the onus was on the nursing team to arrange the twice weekly visits appropriately. Sometimes, individual nurses would ring individual carers to make arrangements, but there was no organisational system to ensure that nurse and carer visits coincided as a matter of routine. ”
Source location
Cecilia EDWARDS · 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
Discuss care coordination with the family and caring nurse, agree the plan, and document it in the electronic care plan.

Verbatim wording from the response
“There are robust arrangements established with local social care agencies and the District Nursing service. However, in this case there was a private carer arrangement, funded and organised by the family. This requires an individualised approach by the service to co-ordinate the care with families to meet specific requirements of the patient. The service has reviewed how it works with families in these circumstances and going forward there will be a discussion with the family and the nurse caring for the patient on this. The plan of care and working together will be agreed with the family and service and will be clearly documented in the electronic patient record care plan.”

Source location
2021-0049-Response-from-Whittington-Hospital-Redacted
Page 2 · response
Published 26 February 2021
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
Monitor family care-coordination arrangements through senior-nurse review, case-note audits and caseload reviews.

Verbatim wording from the response
“This will be monitored on a regular basis by the senior nurses and included in future case note audits and caseload reviews.”

Source location
2021-0049-Response-from-Whittington-Hospital-Redacted
Page 3 · response
Published 26 February 2021
Open published response
13 Nov2019
Mid Kent and Medway
Concerns raised2
1. Failure to identify missed visits through the Missed Visit protocol
2. Incorrect scheduling of required district nursing visits
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dorothy June MACEY · 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

Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

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 identify missed visits through the Missed Visit protocol
Wider context from the report
“(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”
Source location
Dorothy June MACEY · Prevention of Future Deaths report
Page 2 · 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
Incorrect scheduling of required district nursing visits
Wider context from the report
“(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”
Source location
Dorothy June MACEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2014
Manchester South
Concerns raised1
1. Failure to arrange District Nurse attendance to redress the legs
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

AUDREY VERA GARLAND · 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

Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.

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 arrange District Nurse attendance to redress the legs
Wider context from the report
“4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs. ”
Source location
AUDREY VERA GARLAND · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to routinely coordinate district nurse and carer visits

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to identify missed visits through the Missed Visit protocol

Incorrect scheduling of required district nursing visits

Concerns raised1

Failure to arrange District Nurse attendance to redress the legs

Actions described in response 2