Recurring concern

Failure to review relevant clinical records before care decisions

First to latest report 23 Aug 2013 — 8 Jun 2026

Reports that mention this concern
54
Times this concern has been raised
59
Stated actions linked to this concern
70

What this concern includes

Includes failures to consult, check, cross-reference or review relevant existing clinical records as part of clinical assessment, prescribing, treatment, admission, transfer, escalation or other care decisions, including review of the correct record set and routine review requirements.

What is not included
  • Excludes failures to retrieve or make records available when the records were not accessible in the first place; those belong to access or record-availability concerns.
  • Excludes deficiencies in the completeness, accuracy or maintenance of the records themselves unless the asserted unsafe condition is also failure to review them.
  • Excludes generic failures to communicate or hand over clinical information where no record-review failure is identified.
  • Excludes non-clinical record reviews, such as administrative, inspection or mortuary monitoring records.

Reports and published responses 54 reports

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

  1. South Yorkshire (Western)

    AI-generated summary

    Darnell Errol Hugh 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

    Darnell Errol Hugh Smith, who had cerebral palsy, scoliosis, sickle cell disease and epilepsy, attended hospital with reduced appetite, respiratory symptoms and no bowel movements, and was later admitted to critical care, intubated and ventilated. He died on 23 November 2022 after developing ventilation-associated pneumonia and type 2 respiratory failure. The principal concerns were missed observations, pain monitoring, provision of fluids, and staff not locating or considering his health passport and individualised care plan, creating a missed opportunity to identify deterioration earlier.

    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 of treating clinicians to consider individualised care plans during admission

    Wider context from the report

    “The Court heard evidence despite a warning 'flag' being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during admission. Individualised care plans are crucial to a patient's care and it is my view that without knowledge or sight of them by treating clinicians there is a real risk of further deaths. ”

    Source location

    Darnell Errol Hugh Smith · 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

    File updated individualised care plans at the front of paper records under a new standard operating procedure.

    Verbatim wording from the response

    “We will continue to file and flag the ICP in the EPR. We have also started to file a copy of the ICP in the front of the patient’s paper record. In order to ensure that staff always have access to the latest version of the ICP, a new standard operating procedure has been introduced (see enclosure). Once an ICP is agreed, the Haemoglobinopathy (HBO) Clinical Nurse Specialist (CNS) prints off a hard copy of the ICP and places this at the front of the patient’s records to ensure that it is easily accessible. The HBO CNS is responsible for ensuring that whenever an ICP is updated that this is placed in the patient’s record and the old version is removed.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 1 · response
    Published 21 March 2024

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    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

    Hold daily multidisciplinary board rounds on Haematology wards and include Haemoglobinopathy Clinical Nurse Specialist attendance.

    Verbatim wording from the response

    “Since March 2023, the Matron, Senior Charge Nurse, CNS team and the HBO Consultants hold a daily (7 days a week) board round on each of the Haematology wards. Board rounds take place between 8:45-9:30am and include a discussion of all new admissions to identify concerns, needs and plans of care. Since August 2023, the HBO CNS attends the MDT board round each morning to discuss any immediate concerns, to agree treatment plans with the attending medical staff, and to provide support and guidance to the nursing teams.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 1 · response
    Published 21 March 2024

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    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

    Create and place individualised care plans for sickle cell patients without an existing plan after board-round review.

    Verbatim wording from the response

    “For any sickle cell disease patient who has not previously attended the Haemoglobinopathy clinic (e.g. a patient who is new to the area), and therefore does not have an ICP, the HBO Clinical Nurse Specialist ensures that an ICP is written following the Board Round and that this is placed in the patient’s record.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

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    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 individualised care plans at discharge, discuss amendments with patients, and update plans through the multidisciplinary team when required.

    Verbatim wording from the response

    “In addition, on discharge, there is now a team review of the patient's ICP to identify if any amendments are required based on the most recent admission, for example if changes were made to pain management requirements. This is discussed with the patient prior to discharge by the HBO CNS or the ward senior nurses. Should any changes be required, the CNS team updates the ICP and discusses changes via the HBO MDT.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

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    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

    Notify the Haemoglobinopathy Clinical Nurse Specialist team of planned admissions and ensure receiving ward staff know about the individualised care plan.

    Verbatim wording from the response

    “All patients with sickle cell disease who are admitted as emergencies are cared for on Haematology wards where the above processes are in place. For planned admissions relating to other primary diagnoses, sickle cell disease patients may be admitted to other wards. On these occasions the HBO CNS team will be made aware of the planned admission and will ensure that the ward staff are aware of the ICP.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

    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

    Develop an action card covering sickle cell care, guidelines, individualised care plans, and pain assessment.

    Verbatim wording from the response

    “To support staff caring for sickle cell disease patients an action card has been developed which includes a brief explanation of sickle cell disease, nursing care requirements, reference to STH sickle cell disease guidelines, information regarding ICPs and the pain assessment tool to be used when caring for sickle cell disease patients (see enclosure).”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

    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

    Deliver individualised care plan training through the sickle cell education programme, with further Haematology nursing training planned.

    Verbatim wording from the response

    “In addition, there is a focus on ICPs within the sickle cell disease educational package. Since commencing this programme of work, 50 Haematology nursing staff have attended training sessions, with a further 33 planned to receive training by July 2024.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

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    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

    Deliver individualised care plan education to Emergency Department staff.

    Verbatim wording from the response

    “Education has also been delivered to staff in the Emergency Department to ensure that they are also aware of ICPs, should a patient present to them rather than coming directly to the Haematology department.”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

    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

    Configure the new Connect electronic patient record to record, flag, and link users to individualised care plans.

    Verbatim wording from the response

    “As part of the preparation for launching our new Connect EPR we have considered how ICPs will be recorded and flagged in the new system. Whilst this is subject to final configuration and testing, it is planned that:”

    Source location

    Response from Sheffield Teaching Hospitals
    Page 2 · response
    Published 21 March 2024

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Gareth Michael Etchells-Heights · 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 Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.

    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 consistent review of medical notes before appointments, assessments, and handovers

    Wider context from the report

    “2. Review of the medical notes There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state. ”

    Source location

    Gareth Michael Etchells-Heights · 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 Standard Operating Procedure specifying how to prepare for clinical reviews, appointments and handovers, including required documentation review.

    Verbatim wording from the response

    “There is no established local guidance on how to prepare for a clinical review, appointment or handover with practice by and is largely being guided by local custom and practice and training. The Directorate Leadership Team will develop a Standard Operating Procedure covering ‘how to prepare for a clinical review’ which will include what documentation should be read as part of the preparation for this by 30 April 2024.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 2023

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    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

    Disseminate the clinical-review preparation procedure to relevant clinical staff through governance, supervision, training and the intranet.

    Verbatim wording from the response

    “On completion, the guide will be disseminated through local governance structures, via supervision and training arrangements to all clinical staff who utilise our electronic patient records and be available on our intranet.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 2023

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    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 clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.

    Verbatim wording from the response

    “We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust. Incorporated within this is a section to guide clinicians around preparing for service user appointments, ensuring they are briefed on the current issues, risks and concerns. It is accepted that this will depend upon the relationship between the service user and their worker. This will enable staff to have an up-to-date understanding of the service user’s condition and mental state.”

    Source location

    2023-0517 Response from Sheffield Health and Social Care - Update
    Page 2 · response
    Published 12 December 2023

    Open published response

  3. East London

    AI-generated summary

    Iris Elaine Fordham · 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

    Iris Elaine Fordham was admitted to hospital after an unwitnessed fall and concerns about her ability to keep herself safe due to Alzheimer’s disease. Failures to complete a falls risk assessment, falls care plan and enhanced care assessment led to the removal of 1:1 care, after which she sustained a fractured neck of femur in a further unwitnessed fall. She underwent surgical repair and died in a step-down care centre; concerns included poor clinical record-keeping, failures in falls-risk management and the absence of action through disciplinary or regulatory channels.

    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 of clinical staff to read essential parts of the clinical record when providing care

    Wider context from the report

    “4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice. ”

    Source location

    Iris Elaine Fordham · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Leicester City and South Leicestershire

    AI-generated summary

    Marie ZARINS · 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

    Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.

    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 review patients’ records before CRISIS team MDT meetings

    Wider context from the report

    “1) I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient’s medication status. This is particularly difficult to understand when the correct medication status is clearly documented in the patient’s core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team). An LPT staff member was candid about the fact that he did not have enough time to review patients’ records before the MDT meetings, this is a grave concern. ”

    Source location

    Marie ZARINS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. East London

    AI-generated summary

    Raquel Mellonie Harper · 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

    Raquel Mellonie Harper attended Whipps Cross Hospital with shortness of breath and difficulty breathing, but a D Dimer test was not carried out and her condition later deteriorated. She suffered a cardiac arrest and died at the hospital on 25 June 2021. Concerns included inadequate history taking, failure to escalate monitoring after a high NEWS score, and disagreement or unclear wording in the Trust’s pulmonary embolism policy.

    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 thorough history taking and verification of baseline oxygen saturation

    Wider context from the report

    “1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI. There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline. The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%. ”

    Source location

    Raquel Mellonie Harper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Hilary Clare (Billy) Guedalla · 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

    Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

    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 consult medical notes and records during leave risk assessment

    Wider context from the report

    “6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment. Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident. ”

    Source location

    Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
    Page 5 · 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

    Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.

    Verbatim wording from the response

    “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 2023

    Open published response

  7. Manchester South

    AI-generated summary

    Ernest Bacon · 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

    Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.

    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 review relevant clinical notes during assessment

    Wider context from the report

    “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover; ”

    Source location

    Ernest Bacon · 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 Trust-wide sepsis improvement programme covering recognition, Sepsis Care Bundle use, antibiotics, blood cultures and deteriorating-patient assessment.

    Verbatim wording from the response

    “Immediately following the inquest touching the death of Mr. Bacon the Trust completed a retrospective root cause analysis investigation into the clinical care of Mr Bacon, and in particular the response to his raised National Early Warning Score (NEWS) and recognition of sepsis. This was also retrospectively reported on the Trust’s incident reporting electronic system. A number of learning points were identified as a result of the investigation and the findings have been used to support a Trust wide sepsis improvement plan.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 30 September 2022

    Open published response

  8. East London

    AI-generated summary

    Daniel Xavier · 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

    Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.

    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 review clinical records before accepting a surgical referral

    Wider context from the report

    “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand. ”

    Source location

    Daniel Xavier · 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 internal professional standards for specialty teams reviewing emergency-department patients, including training on locating relevant electronic records information.

    Verbatim wording from the response

    “The site is developing internal professional standards for speciality teams reviewing patients in the emergency department. This will include training on where to find all relevant information including tests carried out and GP consultation within the electronic patient records system. The expectation is to have these agreed by the end of October 2022.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 23 September 2022

    Open published response

  9. West Yorkshire (Western)

    AI-generated summary

    Edward Arthur AKROYD · 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

    Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.

    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 review earlier clinical records

    Wider context from the report

    “4. In evidence, Mrs Akroyd attendant midwife at Calderdale Royal Hospital did not appear to acknowledge that there was a need for her to continue to undertake regular monitoring of Mrs Akroyds Blood pressure in light of earlier readings and to escalate to either a doctor or labour ward co-ordinator, I am concerned that if similar circumstances were to re-occur, this poses a risk to the wellbeing of expectant mother and her unborn child. The same midwife also in evidence appeared to state that there was no need to review Mrs Akroyds earlier records as a verbal handover had been made, once again I am concerned that if this were to reoccur, it may pose a risk to the wellbeing to expectant mother and child. ”

    Source location

    Edward Arthur AKROYD · 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 of registrar to review medical notes and records

    Wider context from the report

    “8. The same registrar in evidence stated that at the time he initially assessed Mrs Akroyd he expected the attendant midwife to provide to him a full update and that there was no necessity for him to have undertaken a review of Mrs Akroyds Medical notes and records. The attendant midwife did not provide a comprehensive summary of Mrs Akroyds medical notes and records. I am concerned that if the same circumstances were to reoccur, there presents a risk to the expectant mother and unborn child. ”

    Source location

    Edward Arthur AKROYD · Prevention of Future Deaths report
    Page 4 · 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

    The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.

    Verbatim wording from the response

    “Please see the response to concern 5 above.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 6 · response
    Published 8 March 2022

    Open published response

  10. East London

    AI-generated summary

    Mr Jason Lennon · 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

    Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been 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 effectively review medical records before assessment

    Wider context from the report

    “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others. Factors which contributed to this failure included; a. CRT staff did not effectively review medical records prior to assessing Jason, b. The CRT did not communicate important clinical information between themselves and external stakeholders. c. The CRT did not adequately document important information arising from the assessment. ”

    Source location

    Mr Jason Lennon · Prevention of Future Deaths report
    Page 3 · 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