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. 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
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Data last updated 7 September 2026