Recurring concern

Unreliable documentation and communication of shared clinical decisions

First to latest report 5 Dec 2014 — 5 Feb 2026

Reports that mention this concern
9
Times this concern has been raised
9
Stated actions linked to this concern
10

What this concern includes

Includes failures to establish, document, communicate or preserve shared clinical decisions, assessment outcomes, specialist advice and resulting actions between professionals involved in patient care, where the deficiency can cause confusion, duplicated or omitted action, or unsafe follow-up.

What is not included
  • Excludes generic communication failures between professionals where no shared clinical decision, assessment outcome, clinical advice or resulting action is the deficient object.
  • Excludes deficiencies in the substantive clinical decision or advice when it was clearly documented and communicated but clinically inappropriate.
  • Excludes general clinical record-keeping failures unrelated to documenting and communicating shared professional decisions.
  • Excludes patient- or family-facing communication failures unless they are part of communicating the shared clinical decision between the responsible professionals.

Reports and published responses 9 reports

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

  1. Manchester South

    AI-generated summary

    His Honour Bruce Caulfield · 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

    His Honour Bruce Caulfield died at Trafford General Hospital on 19 August 2025 from complications arising from coronary artery disease, against a background including an acute on chronic subdural haematoma requiring surgery, hypertension and frailty. Concerns included the delay between a family member requesting medical review and the review taking place, whether nursing practices ensured vulnerable patients received adequate hydration and nutrition, and whether measures relating to communication about sitting-out recommendations were in place across the Trust.

    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 communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust

    Wider context from the report

    “3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, I am concerned that comparable measures may not be in place across the Trust as a whole. ”

    Source location

    His Honour Bruce Caulfield · 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

    Maintain consistent Trust-wide use of seating charts and documentation of allied health professional recommendations in HIVE for communication and care planning.

    Verbatim wording from the response

    “I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 9 · response
    Published 10 February 2026

    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

    Extend the Wythenshawe audit of physiotherapy assessments and nursing review processes across the Trust and report findings through hospital quality and safety groups.

    Verbatim wording from the response

    “For patients sitting out for the first time, or where fatigue risk is identified, AHP staff undertake structured assessments including medical history, baseline function, muscle strength, sitting balance and cognition. Recommendations regarding transfer method and seating are documented in HIVE and verbally handed over to nursing colleagues. Nursing staff implement these recommendations in conjunction with moving and handling risk assessments and ongoing observation.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 9 · response
    Published 10 February 2026

    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

    The Trust disputes that communication and documentation measures for sitting-out recommendations were isolated to Doyle Ward, stating they apply consistently across all inpatient areas.

    Verbatim wording from the response

    “I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 9 · response
    Published 10 February 2026

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Ann Margaret Cotgrave · 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 Margaret Cotgrave was admitted to Glan Clwyd Hospital on 31 March 2022 for investigation of jaundice, underwent ERCP on 19 April, sustained a perforation, and died on 3 May 2022. The principal concern was that discussions and advice between Glan Clwyd and a tertiary centre were not documented, and there was no formal documented process for such referrals and advice.

    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 formal documented process for referrals and subsequent advice

    Wider context from the report

    “That there was no record of any discussions which took place between Glan Clwyd and the tertiary centre and no formal documented process in relation to such referrals and the subsequent advice which was provided and thereafter acted upon. ”

    Source location

    Ann Margaret Cotgrave · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Jordan George James Fogg Howarth · 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

    Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.

    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 document consultant clinical discussions

    Wider context from the report

    “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes. 3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team. 4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes. ”

    Source location

    Jordan George James Fogg Howarth · 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

    Use an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.

    Verbatim wording from the response

    “In response to this particular point the ICU team have updated and amended the daily review chart to include a specific section for microbiology input. All patients on ITU are”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 1 · response
    Published 9 May 2024

    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

    The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.

    Verbatim wording from the response

    “Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a recurrence of what happened to Mr Howarth.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 9 May 2024

    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 consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.

    Verbatim wording from the response

    “The Trust follow the General Medical Council (GMC) guidance that supports the recommendation, that every patient admitted to hospital will have a named, identifiable clinician assigned to them. This will help to make sure care is properly coordinated. Mr Howarth’s care was reviewed by several consultants during his admission: ISGU ████████ each discussed and referred this gentleman’s care to other specialisms as required.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 5 · response
    Published 9 May 2024

    Open published response

  4. Manchester North

    AI-generated summary

    Stanislav Mucha · 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

    Stanislav Mucha, aged 17, died after jumping from a height at the Rock centre in Bury, sustaining catastrophic injuries. The report raised concerns about the lack of notes from an independent psychiatrist and the absence of documented agreement between professionals about the outcome of a mental health assessment and the actions required.

    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 documented agreement on assessment outcomes between professionals

    Wider context from the report

    “2. Following the assessment on the 22nd January 2021 there was no documented agreement as to the outcome of the assessment between all professionals. This would have negated the confusion and lack of understanding as to what had occurred and the actions required. ”

    Source location

    Stanislav Mucha · 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

    The Mental Health Act assessment system is designed to produce clear outcomes, with disagreement between assessors serving as an intended safeguard.

    Verbatim wording from the response

    “Our initial thoughts on this are that the way the system is designed means that there should not be a lack of clarity or ability to come to a clear outcome. Outcomes of MHA assessments are decided by any one of the 3 assessors (1st rec doctor, S12 doctor, AMHP) not recommending compulsory powers and then the AMHP having a final veto on the application.”

    Source location

    Response from Royal College of Psychiatrits
    Page 1 · response
    Published 30 September 2022

    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

    AMHPs are responsible for recording assessment outcomes and communicating decisions and reasons to relevant professionals.

    Verbatim wording from the response

    “The Mental Health Act 1983 Code of Practice explicitly places the duty to record the outcome of an assessment on the Approved Mental Health Professional (AMHP). If the AMHP believed that an assessment had taken place, this should have been recorded and communicated to the Section 12 doctors. Relevant sections of the Code of Practice are below:”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 30 September 2022

    Open published response

  5. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Alex Louise Shaw · 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

    Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.

    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 consistently document the content and timing of inter-hospital clinical conversations

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate. (2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented. (3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations. ”

    Source location

    Alex Louise Shaw · 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 structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.

    Verbatim wording from the response

    “1) The paediatric team are in the process of developing a facility on the Trust electronic Iportal System which will provide a structured note ‘Paediatric Advice Proforma’ to aid electronic documentation of conversations between hospitals when seeking advice on patient care; this will include prompts for important discussion points and will have mandatory fields for vital signs (such as heart rate, BP etc.) which will ensure that the clinician includes such information in conversation. Matters are currently being developed with the IT team and we hope to have a solution by September 2021.”

    Source location

    2021-0141-Response-from-Royal-Stoke-University-Hospital-Redacted
    Page 1 · response
    Published 7 May 2021

    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

    Scope improvements to recording patient information for patients needing specialist advice while off site.

    Verbatim wording from the response

    “It is acknowledged that this will result in inconsistencies in practice and as a result, the Trust’s Chief Clinical Information Officer (CCIO) as Associate Chief Medical Officer for IT and Information, together with the Trust’s Chief Technology Officer and Data Protection Officer for the Trust are scoping how the recording of information pertaining to patients who are not on our premises but who need specialist clinical advice can be improved.”

    Source location

    2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
    Page 2 · response
    Published 7 May 2021

    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

    Work with the Norse supplier to transition to the system’s latest version and additional features.

    Verbatim wording from the response

    “We have a limited deployment of an electronic product called Norse. This facilitates a typed ongoing conversation between a clinician’s at this Trust and at another centre. This system includes some features including an ability for our staff to request baseline information at the start of the conversation and include other clinicians as appropriate in the conversation. At conclusion of the discussion, it is then possible to retain the detail of the dialogue.”

    Source location

    2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
    Page 2 · response
    Published 7 May 2021

    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

    Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.

    Verbatim wording from the response

    “We have a limited deployment of an electronic product called Norse. This facilitates a typed ongoing conversation between a clinician’s at this Trust and at another centre. This system includes some features including an ability for our staff to request baseline information at the start of the conversation and include other clinicians as appropriate in the conversation. At conclusion of the discussion, it is then possible to retain the detail of the dialogue.”

    Source location

    2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
    Page 2 · response
    Published 7 May 2021

    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

    Remind clinicians to keep contemporaneous notes of advice given to district general hospitals by placing a note in patients’ records.

    Verbatim wording from the response

    “We will remind clinicians of the need to keep contemporaneous notes about advice given about advice given to district general hospitals by placing a note in patient’s record.”

    Source location

    2021-0141-Response-from-Birmingham-Womens-and-Childrens-NHSFT-Redacted
    Page 2 · response
    Published 7 May 2021

    Open published response

  6. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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 record pharmacist-clinician discussions and advice

    Wider context from the report

    “3. The Court heard of discussions which take place between the Pharmacists and clinicians. These can take place at times when the pharmacist is off the ward. In these circumstances there is no ability for the pharmacist to record such discussions. There was no record anywhere of any discussions on the 30th December 2016 or the 9th January 2017 and any such advice provided, so there was no way of confirming if such conversations had taken place. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Newcastle upon Tyne

    AI-generated summary

    Sheila Mary Hynes · 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 Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.

    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 involve and record discussions with the primary surgeon before remounting the valve

    Wider context from the report

    “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use. Concerns arising are: a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded. b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount. c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded. d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue. ”

    Source location

    Sheila Mary Hynes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Birmingham and Solihull

    AI-generated summary

    Richard Paul Martin Grant · 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

    Richard Paul Martin Grant was found deceased in his car in his garage on 7 January 2016 following inhalation of helium gas. He had previously self-harmed and threatened suicide, but his counselling referral was sent to the wrong team and an appointment was arranged for 22 February 2016. The report identified concerns about delays and failures in referring him to the appropriate mental health service and in informing his GP about the assessment and its outcome.

    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

    Delays in sending assessment circumstances and outcomes to GPs

    Wider context from the report

    “(2) A letter detailing ████████ assessment and the outcome of it was not sent to Mr. Grant’s GP until at least the 22nd December 2015, ████████ did not know why there was such a delay nor whether it was typical. There is a clear risk to life from GPs not being aware of the circumstances and outcome of assessments of patients who have attempted suicide for such an extended period. ”

    Source location

    Richard Paul Martin Grant · 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 an MHLS standard requiring assessment letters to be drafted within the same or following shift and dispatched within three working days.

    Verbatim wording from the response

    “4. MHLS standard developed requiring all letters are drafted within the same or following shift and are dispatched within 3 working days. (Completed)”

    Source location

    2016-0157-Response-by-Black-Country-NHS
    Page 3 · response
    Published 21 April 2016

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Paul Leslie HYDE · 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

    Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

    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

    Poor documentation of referral-management decisions

    Wider context from the report

    “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

    Source location

    Paul Leslie HYDE · 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

    Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.

    Verbatim wording from the response

    “The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.”

    Source location

    2014-0527-Response-by-Sussex-Partnership-NHS
    Page 1 · response
    Published 5 December 2014

    Open published response

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