Recurring concern

Failure to maintain accurate next-of-kin information in healthcare records

First to latest report 27 Aug 2015 — 6 Mar 2026

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures to record, verify, update or preserve next-of-kin details in healthcare records or directly associated clinical information systems, including incorrect, missing or outdated details that can impair welfare contact, discharge planning, continuity of care or safety communication.

What is not included
  • Excludes failures to involve, consult or communicate with next of kin when the recorded information was accurate and available; those are family-involvement or communication concerns.
  • Excludes generic clinical-record deficiencies where next-of-kin information is not the material object.
  • Excludes prison-specific next-of-kin processes where custody provides the more specific supported boundary.
  • Excludes failures concerning family contact details when no next-of-kin or equivalent designated-contact context is identified.

Reports and published responses 5 reports

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

  1. North London

    AI-generated summary

    Asher Blackman · 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

    Asher Blackman died in hospital on 21 September 2025 after collapsing at home, where he was found to be profoundly hypoglycaemic. Concerns included the District Nurses’ failure to record next-of-kin details or procedures for inability to gain access, and a no-access policy that did not address police involvement where the patient’s life might be at risk.

    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 record next of kin details in the initial assessment

    Wider context from the report

    “That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. ”

    Source location

    Asher Blackman · Prevention of Future Deaths report
    Page 1 · 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

    Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.

    Verbatim wording from the response

    “On behalf of Central London Community Healthcare NHS Trust (CLCH), I would like to express again our sincere condolences to Mr Blackman’s family. The Trust has carefully reviewed the matters raised in your report and, to ensure that we fully reflect on and learn from the events leading to the death of Mr Blackman, has undertaken a programme of Trust-wide engagement events. These sessions have been designed to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’, ensuring that current approaches to managing situations where clinical staff are unable to gain access to a patient appropriately identify and assess all potential risks, and that proportionate mitigations are implemented to meet individual patient need.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 1 · response
    Published 10 March 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

    Review District Nursing referral forms, initial assessment documentation, and clinical-system configurations for contact-information capture and visibility.

    Verbatim wording from the response

    “The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations to ensure that:”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 2 · response
    Published 10 March 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

    Update electronic patient records with prompts and alerts supporting completion and verification of next-of-kin and emergency-contact information.

    Verbatim wording from the response

    “In addition, the Trust has a long-term plan to improve visibility of this information on the system, and we are working with the Information Management Team to update the electronic patient record system to include prompts and alerts to support completion and verification of this information.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 2 · response
    Published 10 March 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

    Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.

    Verbatim wording from the response

    “Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 3 · response
    Published 10 March 2026

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    CHRISTOPHER 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

    Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional 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

    Incorrect recording of next-of-kin information in medical records

    Wider context from the report

    “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care. ”

    Source location

    CHRISTOPHER SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Avon

    AI-generated summary

    Christopher Michael SEAL · 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

    Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.

    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 record next-of-kin details on RIO

    Wider context from the report

    “3. There were no next of kin details recorded on RIO – I was told that you use The National Spine to automatically populate this information however the next of kin details were on the hospital records for the A&E attendance and I was told that they use The National Spine. Is this system being used properly? ”

    Source location

    Christopher Michael SEAL · 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

    Develop a RiO front-screen indicator showing Next of Kin or emergency-contact absence.

    Verbatim wording from the response

    “The Trust is working to find a technical solution to create a work list of records that require synchronisation in order that administrative staff might be able to complete this task and improve compliance (target completion date 31 August 2019). There is a secondary issue that where there is no Next of Kin recorded, the absence of this is not evident. There is presently a development request to place an indicator on the front screen of the record showing the Next of Kin/In Case of Emergency contact, or the absence of that record in red, in order to make this more obvious to the clinician/user (target completion date 31 July 2019).”

    Source location

    2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
    Page 2 · response
    Published 24 May 2019

    Open published response

  4. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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 record risk, contact details, appointment information and follow-up arrangements

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Frederick Sutton · 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

    Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

    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 maintain accurate next-of-kin information

    Wider context from the report

    “(8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details, where the wife of the deceased was shown as n.o.k when in fact she had died in 2008. ”

    Source location

    Frederick Sutton · Prevention of Future Deaths report
    Page 1 · 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