Recurring concern

Unreliable arrangement and communication of patient appointments and follow-up

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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. Inner North London

    AI-generated summary

    Terence Darren ADAMS · 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

    Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

    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 follow up non-attendance at the second reception screen

    Wider context from the report

    “5. On the morning he died, Mr Adams should have attended his second reception screen, also known as the well man clinic. When he did not arrive, the healthcare nurse did not attempt to find out why or to secure his attendance. ”

    Source location

    Terence Darren ADAMS · 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

    Nurses cannot chase prisoners who miss appointments during clinics because workload makes this impractical and inefficient.

    Verbatim wording from the response

    “When a patient is booked for a clinic but does not attend (DNA), nurses will investigate and chase up that person once the clinic is over. It would not be possible, nor an efficient use of clinical time, for nurses to chase up prisoners during the course of a clinic. With 15-20 new receptions everyday (Pentonville being a remand prison and thus having a high population turnover), if nurses chased up DNA prisoners during the course of the clinic, they would spend their time doing nothing else.”

    Source location

    Response from Care UK
    Page 4 · response
    Published 26 July 2016

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Marion Rose HOWES · 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

    Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

    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 timely patient notification of cancer-diagnosis and specialist appointments

    Wider context from the report

    “(2) At this Inquest I was told that hospital was not considered the best place to impart the difficult news of a cancer and that this is dealt with by a Outpatients appointment being sent for the patient to meet the surgeon and the specialist nurse. In this particular case the patient died and in fact never knew the date of the appointment allocated, but the appointment of the specialist nurse, when the diagnosis is made, would be helpful and timeous and enable the patient to understand and prepare for what is to come. It seems to me that it would be a very much kinder way to proceed and would also mean that the sensible patient would be preparing him or herself for the surgery which is likely to follow. ”

    Source location

    Marion Rose HOWES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester West

    AI-generated summary

    Suzanne Samantha Greenwood · 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

    Suzanne Samantha Greenwood died at Haslam Park, Bolton, on 23 December 2014 after being found collapsed and unresponsive with a ligature around her neck; she had also taken Zopiclone and alcohol. The principal concerns were the absence of contact after she failed to attend appointments, her not being discharged or reported to her General Practitioner, and the lack of systems and timescales for managing missed appointments and notifying other healthcare professionals.

    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 patients after missed appointments

    Wider context from the report

    “1. During the Inquest evidence was heard that i. Mrs Greenwood had not been seen by ████████ at the Priory Hospital, Altrincham after her last review on the 21st November 2013 prior to her death on the 23rd December 2014. She had failed to attend appointments in January 2014 but there had been no contact with her, either by telephone or letter, following her failure to attend the appointment on the 16th January 2014. ii. Mrs Greenwood had not been discharged by ████████ following her failure to attend her appointment on the 16th January 2014 and before her death on the 23rd December 2014 but there had been no contact with her for a period exceeding 11 months. iii. ████████ had not made any contact with the General Practitioner to confirm Mrs Greenwood’s failure to attend her appointments in January 2014 and that she had not been seen after the 21st November 2013, which is a particular concern when an Advanced Nurse Practitioner reduced the medication initially prescribed by ████████ which she had the authority to reduce, in circumstances where ████████ had not seen Mrs Greenwood since the 21st November 2013. iv. There are no systems, either in ████████ private practice or in the Priory Hospital, Altrincham to contact patients following a failure to attend appointments and to consider the discharge of patients when a patient repeatedly fails to attend appointments over a period of time. There are no timescales with regard to the discharge of patients and no system to contact General Practitioners or other health professionals in relation to the failure to attend appointments, particularly in circumstances where other health professionals are likely to continue to treat patients after the missed appointments, including changes in medication. The importance of discharge within a reasonable period after a failure to attend appointments is important to enable other health professionals involved in continuing care to be aware of the non-attendance at appointments and the discharge. The fact that there has been no reported failure to attend appointments and no reported discharge would be misleading to other health professionals involved in continuing care, particularly when a patient has not been seen for a period in excess of 12 months and that information would not be available to other health professionals in the absence of information from the Hospital. There is a need for health professionals involved in the continuing care of a patient to be kept informed as to the treatment or non-treatment of the patient at a hospital when considering further treatment in the community. 2. I request you to consider the above concerns and for both ████████ and The Priory Hospital, Altrincham to carry out a review with regard to the following. i. The systems procedures, policies and protocols in relation to contact with patients who fail to attend appointments. ii. The systems, procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that the patient will be discharged unless there is either contact or an appointment within a defined period. iii. The systems, procedures, policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments with notification to General Practitioners or other health professionals of the patient’s failure to attend appointments and their discharge from hospital. The review should consider timescales in relation to discharge when a patient has failed to attend appointments for a specific period of time. iv. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. ”

    Source location

    Suzanne Samantha Greenwood · 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

    Complete a review of systems, procedures, policies and protocols governing contact with patients who fail to attend appointments.

    Verbatim wording from the response

    “1. You asked that a review is carried out of the systems, procedures, policies and protocols in relation to contact with patients who fail to attend appointments.”

    Source location

    2015-0370-Response-by-The-Priory_Redacted
    Page 1 · response
    Published 9 October 2015

    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 independent doctors to send final non-attendance letters to patients and relevant professionals, including medication, aftercare, crisis actions and future assistance options.

    Verbatim wording from the response

    “In response to 2 and 3 please note that we have given full consideration to these matters and have now made the following requirements explicit in Policy H105: Practising Privileges for Independent Doctors:”

    Source location

    2015-0370-Response-by-The-Priory_Redacted
    Page 2 · response
    Published 9 October 2015

    Open published response

  4. Surrey

    AI-generated summary

    George Nigel Palmer · 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

    George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be made.

    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 appropriate follow-up letters to patients after non-contact

    Wider context from the report

    “During the inquest ████████ Registered Mental Health Nurse, provided helpful evidence and the following concerns were highlighted: - • Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. • Appropriateness of follow up letters to the patient in the event of non-contact. I would ask that you consider giving further consideration to the above to ensure that there is no further repetition. ”

    Source location

    George Nigel Palmer · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Rita Paton · 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

    Rita Paton, who had type 2 diabetes, hypertension, chronic kidney disease and dementia, died on 8 December 2014 from ischaemic and hypertensive heart disease, contributed to by chronic kidney disease and diabetes mellitus. Concerns included the lack of a system to ensure requested blood tests were completed and reported, the absence of a clear process for involving family when a patient lacks capacity to make decisions about appointments, and limited access to patients’ medical and medication information for attending medical crews.

    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 a back-up process to ensure follow-up of medical appointments for patients lacking decision-making capacity

    Wider context from the report

    “(2) Mrs Paton’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending medical appointments they might be inadvertently missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in a patient’s best interests to use this approach, to ensure that follow-up occurs. It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘back-up’ process in place and that future deaths could occur as a consequence. ”

    Source location

    Rita Paton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. South Lincolnshire

    AI-generated summary

    John William THORPE · 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

    John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.

    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 or record follow-up contact after clinical care

    Wider context from the report

    “2 That no intention to follow him up, with a definite appointment being given or by telephone contact, is recorded in the clinical records. ”

    Source location

    John William THORPE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Sunderland

    AI-generated summary

    Thomas David Dixon · 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

    Thomas David Dixon had bladder cancer and died at St Benedict’s Hospice on 29 March 2014 from metastatic transitional cell carcinoma of the bladder. Concerns included failures to arrange follow-up and an urgent procedure, missing referral documentation, and a lack of systems to identify and rectify these problems, with potential implications for other 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 provide follow-up appointments within the required timeframe

    Wider context from the report

    “(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014 (4) There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up. I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements. However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths ”

    Source location

    Thomas David Dixon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner South London

    AI-generated summary

    Gary Richards · 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

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    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 reliable communication pathways for follow-up

    Wider context from the report

    “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · 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

    Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.

    Verbatim wording from the response

    “A further review of Mr Richards’ records indicates that when he was seen in the outpatient clinic in June, the service was aware of his mobile phone number. In fact, he had been called the day before by a social worker at the community team and asked to attend the outpatient appointment on 14 June as his GP had been concerned that he had again reported suicidal ideation.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    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

    Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.

    Verbatim wording from the response

    “She tried, using the number on file, but it was unobtainable. There was no other way of making contact with Mr Richards, so she left a message at the A&E department asking him to make contact with her should he re-present as he had booked an appointment to see her on 2 October.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 3 · response
    Published 9 May 2014

    Open published response

  9. Inner North London

    AI-generated summary

    Frank POPE · 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

    Frank Pope had ischaemic heart disease, peripheral vascular disease and an abdominal aortic aneurysm, and was admitted to hospital several times in 2013 for ischaemic colitis. He died on 12 December 2013 after rapidly deteriorating from a further episode of ischaemic colitis; concerns were raised that patients who lack capacity to manage follow-up appointments may miss them when family members are not included in correspondence, with no clear backup process identified.

    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 a back-up process for patients who lack capacity to make decisions about attending follow-up consultations

    Wider context from the report

    “(1) Mr Pope’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending follow-up consultations, appointments might be missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient’s best interests to use this approach, to ensure follow-up occurs. It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘back-up’ process in place and that future deaths could occur as a consequence. ”

    Source location

    Frank POPE · 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

    Failure to involve family members in follow-up correspondence where patients lack capacity to make decisions about attending follow-up consultations

    Wider context from the report

    “(1) Mr Pope’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending follow-up consultations, appointments might be missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient’s best interests to use this approach, to ensure follow-up occurs. It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘back-up’ process in place and that future deaths could occur as a consequence. ”

    Source location

    Frank POPE · 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

    Send GPs a bulletin reminding them to identify vulnerable or capacity-lacking patients and request copied appointment letters for nominated representatives.

    Verbatim wording from the response

    “To conclude, I hope you are assured that the Trust has appropriate and robust processes in place with respect to patients who lack capacity to make decisions to attend their out-patient appointments. Having considered your recommendation, we do not feel that our processes or the Elective Access Policy require any changes; however we do feel it would be helpful to send a communication to all the GPs in our area reminding them of our safety net processes for patients who lack capacity to attend appointments.”

    Source location

    2014-0216-Response-by-Whittington-Health-NHS
    Page 2 · response
    Published 8 May 2014

    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 processes and the Elective Access Policy are considered sufficient for supporting patients who lack capacity to attend appointments, so no changes are required.

    Verbatim wording from the response

    “If a patient is deemed not to have capacity, and a formal letter or email request from the GP, family member/representative or clinician is made to the Patient Access Centre, an alert will be raised prompting the staff to copy appointment letters for that patient to family members, GP or the appointed representative. The Patient Access Supervisor will place the alert on the Trust’s Patient Administration System, which flags this request each time a member of staff makes an appointment. The system will show the name and address of the person to whom the copies should be sent. Unfortunately in Mr Pope’s case, such an alert was not requested and therefore his out-patient appointment letters were not copied to anyone. Had such a request been received for Mr Pope, we would have been accommodated it, as described.”

    Source location

    2014-0216-Response-by-Whittington-Health-NHS
    Page 2 · response
    Published 8 May 2014

    Open published response

  10. Surrey

    AI-generated summary

    Phyllis Barnes · 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

    Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.

    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

    Unreliable promised telephone follow-up

    Wider context from the report

    “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised ”

    Source location

    Phyllis Barnes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026