Recurring concern

Unreliable arrangement and communication of patient appointments and follow-up

First to latest report 30 Jan 2013 — 23 Oct 2025

Reports that mention this concern
42
Times this concern has been raised
46
Stated actions linked to this concern
46

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.

What is 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 and published responses 42 reports

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

  1. Berkshire

    AI-generated summary

    Mrs Nutbeam · 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

    Mrs Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

    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 patients with a letter accompanying them to subsequent appointments

    Wider context from the report

    “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment. ”

    Source location

    Mrs Nutbeam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Gareth Mark Slater · 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

    Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

    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 follow-up appointments at discharge

    Wider context from the report

    “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of discharge. ”

    Source location

    Gareth Mark Slater · Prevention of Future Deaths report
    Page 2 · 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