Recurring concern

Unreliable arrangement and communication of patient appointments and follow-up

Pin Get email alerts Request correction

First reported 30 Jan 2013•Latest report 23 Oct 2025

Definition

What this concern includes

Includes failures of the patient-facing appointment communication and follow-up process, including reminders, contact after non-attendance, communication of appointment requirements, and communication or arrangement of required repeat or subsequent appointments.

Not included

  • Excludes failures to provide the clinical assessment or treatment itself where appointment communication is not the concern.
  • Excludes generic record-keeping, staffing or information-transfer failures unless they directly make patient appointment or follow-up communication unreliable.
  • Excludes communication unrelated to arranging, confirming, changing or following up a patient appointment.
Reports
42

Distinct published reports

Individual concerns
46

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
46

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.

Department of Health and Social Care5
NHS England4
Care Quality Commission3
Greater Manchester Health and Social Care Partnership2
Midlands Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
Pennine Care NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
CAMHS East – Cross Street Clinic1
Care UK1
Central and North West London NHS Foundation Trust1
City Health Care Partnership CIC1
Community Mental Health Recovery Services (Surrey and Borders Partnership)1
County Durham and Darlington NHS Foundation 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. Birmingham and Solihull

    AI-generated summary

    Conall Patrick Gould · 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

    Conall Patrick Gould died at Queen Elizabeth Hospital in Birmingham on 13 February 2017 after behaving erratically and collapsing; the medical cause of death was recorded as ecstasy use. The report raised concerns that arrangements for his community mental health follow-up appointment after discharge were not communicated to him or his parents, and that the absence of a clear protocol or written confirmation created a risk that follow-up opportunities could be missed.

    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 ensure that service users and carers receive follow-up appointment details on discharge

    Wider context from the report

    “1. At the time of discharge from Holywell Hospital on the 30th January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2nd February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence of ████████ Consultant Psychiatrist, who saw Conall and his father on the 30th January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust ████████ had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30th January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4. The evidence of ████████ who conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost. ”

    Source location

    Conall Patrick Gould · 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

    Implement enhanced discharge documentation requiring written follow-up details, contact numbers, and agreed information for patients and carers.

    Verbatim wording from the response

    “The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 day follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge. This protocol also directs that a relative/concerned other, identified by the patient, will also be provided with this written information when consent to do so has been given by the patient.”

    Source location

    Conall-Patrick-Response
    Page 1 · response
    Published 28 September 2017

    Open published response

  2. Manchester South

    AI-generated summary

    Matthew Robert 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

    Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.

    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 ensure follow-up appointments are booked before discharge

    Wider context from the report

    “2. The follow up appointment was not made for Mr Edwards on his discharge. When the discharge summary was dispatched subsequently this was not picked up and there was no system in place to ensure that follow up appointments had been booked prior to discharge. ”

    Source location

    Matthew Robert 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

    Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.

    Verbatim wording from the response

    “I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.”

    Source location

    Matthew-Edwards-Response
    Page 2 · response
    Published 17 July 2017

    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

    Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.

    Verbatim wording from the response

    “This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.”

    Source location

    Matthew-Edwards-Response
    Page 3 · response
    Published 17 July 2017

    Open published response

  3. Preston and East Lancashire

    AI-generated summary

    Robert Cardwell · 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

    Robert Cardwell was under the care of a Home Treatment Team but was discharged after information about his missed appointment and request for a further appointment was not passed to the multidisciplinary team. He later expressed suicidal thoughts, described a plan to hang himself using a football scarf, and was found deceased at home on 29 September 2016 after hanging himself. Concerns included failures in communication, failure to discuss or follow up his request for an appointment, and inadequate record keeping during multidisciplinary team meetings.

    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 MDT follow-up decisions to patients

    Wider context from the report

    “On the 6th August 2016 Mr Cardwell was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr Cardwell was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the Duty Practitioner to the MDT on the 10th August 2016. However, the MDT did not discuss Mr Cardwell and nothing was recorded about him. No-one contacted Mr Cardwell back to advise him as to whether or not he would have an appointment with the HTT. I heard evidence that the MDT meeting could be disorganised. I am concerned that Mr Cardwell was not considered by the team, despite the message being handed over to them. I am also concerned about a lack of record keeping during the MDT. Even where patients are discussed, the notes appear to be very brief. ”

    Source location

    Robert Cardwell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    Jamie Pashley · 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

    Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    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 fixed post-discharge appointments after detoxification

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · 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

    Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.

    Verbatim wording from the response

    “The Trust’s view is that a more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient’s GP may be a more effective approach. There is currently a trial underway in which King’s College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    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

    Existing motivational models and pre-discharge links to appropriate third-sector services are preferred over fixed hospital follow-up appointments.

    Verbatim wording from the response

    “Alcohol dependency patients have notoriously very high DNA rates. As a result, providing fixed follow-up appointments for this category of patients after detoxification as an in-patient and signposting would likely generate a high level of wasted appointments. This is why it is common practice within the NHS to instead use motivational models and to ensure patients as far as practicable are linked in with appropriate third-sector services prior to discharge rather than providing further hospital appointments.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 1 · response
    Published 4 August 2017

    Open published response

  5. Staffordshire South

    AI-generated summary

    Lester John STACEY · 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

    Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.

    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 follow-up appointments before discharge

    Wider context from the report

    “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016. There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication. ”

    Source location

    Lester John STACEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. 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 provide proactive follow-up after a declined appointment

    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

  7. Nottinghamshire

    AI-generated summary

    Sheila Stokes · 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

    Sheila Stokes had a large abdominal aortic aneurysm diagnosed in July 2015 and died at home on 26 January 2016 after it ruptured. The report identified delays in arranging appointments, acting on the radiology alert, discussing the case, and sending information needed for a custom-made graft. It also raised concerns about administrative systems, communication, the trust’s investigation, and the completeness of statements provided to the coroner.

    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 contact and follow up patients who DNA appointments

    Wider context from the report

    “1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to be copied to their GPs. ”

    Source location

    Sheila Stokes · 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

    Failure to copy DNA appointment correspondence to GPs

    Wider context from the report

    “1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to be copied to their GPs. ”

    Source location

    Sheila Stokes · 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

    Relaunch and standardize the Trust-wide DNA process, including same-day clinician review, documented actions, safeguarding escalation, and GP notification on discharge.

    Verbatim wording from the response

    “The DNA process was re-launched in June 2016 (see the flow chart attached) as it was clear that there was not a consistent approach to dealing with DNAs across the Trust. This process ensures that DNAs are dealt with on the day. Clinic staff will place a DNA sticker into the patient’s notes and ensure this is completed by the clinician who indicates the action to be taken e.g. further appointment within given timescale or discharge. The clinician can also highlight if there are any safeguarding concerns and request the notes to be returned to their Patient Pathway Co-ordinator (PPC) for further action to be taken.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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

    Conduct regular audits of the DNA process to verify adherence.

    Verbatim wording from the response

    “A number of managers involved in the Outpatient service carry out DNA audits on a regular basis to ensure that the process is being adhered to. We are happy to provide audits of this process should you require.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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

    Pilot scanning DNA reconciliation slips into Medway to create a permanent record of requested actions.

    Verbatim wording from the response

    “The receptionist will input an outcome for the appointment and makes any further appointments as requested by the clinician before sending the notes to the PPC. If the patient is discharged at the clinician’s request a DNA letter will be sent to both the patient and their GP to indicate the discharge has taken place. However, prior to discharging the patient a check is made to ensure that the patient was sent an appointment letter and also that the address for the patient recorded on Medway, matches that on the Summary Care Record. The reconciliation slips which indicate the actions requested by the clinician are destroyed after completion of the task. However, the DNA sticker remains within the case notes permanently and is a record of the request. The Trust is planning to commence a pilot of scanning reconciliation slips into Medway, providing a permanent record.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 2017

    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

    An earlier vascular appointment could not be provided because clinic capacity was limited during the relevant period.

    Verbatim wording from the response

    “Mrs S did not attend this appointment and this was inputted onto our system as a ‘DNA’ and she was to have a new appointment made (see appendix 3). We believe that our staff telephoned Mrs S the following day (28th July) to make another appointment for her which was for the 14th September and from the comment made, it was noted that she would like to be seen earlier if there was opportunity by reason of a cancellation (see appendix 4). We believe that it is likely that this date of 14 ████████”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 February 2017

    Open published response

  8. Surrey

    AI-generated summary

    Matthew RUSSELL · 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

    Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

    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 effectively follow up patients who miss pre-booked clinical appointments

    Wider context from the report

    “c. An effective procedure for following up patients who fail to attend pre-booked appointments with clinicians. ”

    Source location

    Matthew RUSSELL · 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

    Operate and share the In-Reach DNA procedure, including same-day follow-up, risk review and rebooking after missed appointments.

    Verbatim wording from the response

    “The CNWL In-Reach Team has a DNA (Did Not Attend) Standard Operating Procedure in place which has been shared and discussed with all staff members.”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 5 · response
    Published 26 February 2017

    Open published response

  9. Isle of Wight

    AI-generated summary

    Ann Hardman · 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

    Ann Hardman attended her GP with a painful swollen left calf and a positive D-Dimer test, but an ultrasound scan at St Mary’s Hospital was suboptimal because of technical limitations associated with her build. On 20 January 2015, after contacting her GP practice about chest pain, she declined advice to call 999 and was shortly afterwards found dead at home. The medical cause of death was pulmonary thromboembolism associated with thrombosis of the deep veins of the left calf. The concern was that the protocol relied on patients returning to their GP to obtain a further scan referral, rather than being automatically advised by the ultrasound department to attend a repeat scan.

    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 automatically arrange and communicate repeat DVT scanning after a negative scan

    Wider context from the report

    “1. I am concerned that when there is a negative scan for a DVT at St Mary’s Hospital, the current protocol relies on the patient returning to their GP and being given another referral form for a further scan 6-8 days later. It was accepted that a better system would be one whereby the patient was automatically told to return for a further scan a week or so later by the ultrasound department, subject to the patient’s GP cancelling this scan, based on their clinical judgement of any review of the initial scan and/or any further examination of the patient. This would remove the chance of patients failing to be told to re-attend for a further scan. ”

    Source location

    Ann Hardman · 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

    Implement a follow-up system booking repeat ultrasound scans 6–8 days after a negative scan and notifying GP practices about non-attendance.

    Verbatim wording from the response

    “I am therefore very pleased to report that we have implemented the following system in line with your suggestion:”

    Source location

    2016-0350-Response-by-Isle-of-Wight-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  10. Plymouth, Torbay and South Devon

    AI-generated summary

    Roy Gordon Millar · 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 Gordon Millar attended hospital with slurred speech and facial droop, and scans identified an abnormality requiring follow-up. The repeat scan results were not sent to the correct consultant, and a requested outpatient appointment was not arranged. A brain tumour was identified after he re-presented with a more severe facial droop, but he died on the date planned for biopsy and debulking surgery; the report also describes failures to book follow-up appointments affecting approximately 146 patients.

    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 book follow-up appointments for discharged patients

    Wider context from the report

    “PHNT instigated a Root Cause Analysis following this incident, a copy of which is enclosed. ████████ the author of the Report and the Trust’s Patient Safety Lead, attended the Inquest. During the course of the hearing it emerged that the Ward Administrat or in the Neurology Department had been recently appointed. She had been trained by her predecessor. Neither the previous nor the current Ward Administrator were aware of their responsibility to book follow-up appointments for patients who had been discharged. Their understanding was that appointments would be arranged by Consultants’ secretaries and it seems apparent that a large number of appointments were made in this way. It emerged during the course of the Inquest that the Ward Administrators in the Neurology Department had not booked follow-up appointments for approximately 26 months. As you will see from the enclosed Root Cause Analysis, PHNT has reviewed 1000 patient admissions and it has revealed that 146 patients die not have follow-up appointments booked. In Mr Millar’s case the evidence I heard was that the follow-up scan being conducted in June 2015 was likely to have led to a biopsy which would have diagnosed the brain tumour. If Mr Millar had undergone earlier surgery, the Inquest heard that he would have had a 50% chance of surviving for a year. ”

    Source location

    Roy Gordon Millar · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
Back to top

Data last updated 7 September 2026