Recurring concern

Failure to provide respectful and empathetic care to vulnerable patients

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First reported 29 Feb 2016•Latest report 8 Nov 2022

Definition

What this concern includes

Includes failures in care delivery where staff lack understanding, empathy or respect for vulnerable patients and that attitude affects judgement, responsiveness or the safety of care, including the anchor's concern about social-work and community-nursing empathy and the concern about confused elderly patients being regarded as a nuisance.

Not included

  • Excludes generic staff training, workload or communication deficiencies unless they directly result in disrespectful, unempathetic or dismissive care toward a vulnerable patient.
  • Excludes ordinary disagreements, dissatisfaction or poor bedside manner where no patient-safety impact or effect on care judgement is identified.
  • Excludes failures involving a named clinical, safeguarding or operational process when that process, rather than staff respect or empathy, is the shared unsafe condition.
  • Excludes discriminatory-care concerns that do not involve an identified effect on the safety or quality of care.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2016–2022

First to latest report issue date

Stated actions
1

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.

NHS Greater Manchester Integrated Care Board1
NHS Heywood, Middleton and Rochdale Clinical Commissioning Group1
Pennine Care NHS Foundation Trust1
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.

  1. Inner North London

    AI-generated summary

    Roy Elton TRAVERS · 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

    Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.

    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 provide non-discriminatory care for confused elderly patients

    Wider context from the report

    “4. Mr Travers’ sons told me at inquest that, when Mr Travers’ was nursed on Mary Seacole Ward, they felt that staff regarded this confused, elderly man as a nuisance. That is clearly unacceptable. In addition, Mr Travers’ family worried that this view of him clouded the judgement of those looking after him. ”

    Source location

    Roy Elton TRAVERS · Prevention of Future Deaths report
    Page 2 · 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

    Existing alerts, one-to-one supervision, documented support and staff skills were considered sufficient to manage the confused patient's needs safely.

    Verbatim wording from the response

    “████████ Ward Manager of Mary Seacole, offers her sincere condolences to Mr Travers’ family. Ms Bakari advises Mr Travers had an electronic alert to notify staff of his additional care needs due to his dementia. Due to his risk of dehydration ████████ herself supported to insert a new intravenous cannula. A 1:1 was also implemented to support his safety (prevention of falls risks) whilst he was being nursed in a side room. There is clear documentation that nursing staff were supporting him with taking oral fluids and offering food and assisted him with his personal hygiene needs. Staff regularly care for patients with confusion but ████████ felt Mr Travers needs while confused were manageable on the ward and appropriate to the skills of the staff.”

    Source location

    Response from Whittington Health NHS Trust
    Page 2 · response
    Published 9 November 2022

    Open published response

  2. Manchester (North)

    AI-generated summary

    Susan Beverley George · 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

    Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

    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

    Unprofessional staff attitudes towards patients and care provision

    Wider context from the report

    “6. Unprofessional staff attitudes towards patient/care provision – two qualified nurses involved in Susan’s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator. Prevailing attitudes such as this, particularly towards vulnerable adult, puts care standards at risk. ”

    Source location

    Susan Beverley George · Prevention of Future Deaths report
    Page 3 · 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

    Undertake a targeted organisational development review to embed a positive ward culture and support team development.

    Verbatim wording from the response

    “There have been some specific actions taken as regards the two nurses identified via the coroner. Although of course we cannot divulge the full details of this action it is appropriate to the allegations highlighted and being managed through the Trusts Conduct and Disciplinary processes and the NMC Fitness to Practice processes. In relation to the overall culture and attitudes on the ward, as previously mentioned the ward now has a substantive ward manager who has instilled a more proactive and positive culture but it is recognised that ward environments have many challenges, with difficulties cases to manage safely, staffing levels and acuity challenges and the need to have a stabilised ward team to foster a positive culture led by senior clinical leaders who are excellent role models and instil expectations”

    Source location

    Susan-George-Response
    Page 5 · response
    Published 29 February 2016

    Open published response
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Data last updated 7 September 2026