Recurring concern

Unsafe operation of multidisciplinary clinical meetings

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First reported 10 Jan 2014•Latest report 27 May 2026

Definition

What this concern includes

Includes failures of explicitly multidisciplinary clinical meetings, ward rounds, CPA meetings or comparable clinical case meetings involving inadequate preparation, relevant-record review, appropriate attendance, patient participation, risk discussion, decision-making, meeting effectiveness or recording where these impair safe care decisions.

Not included

  • Excludes non-clinical, governance, learning or administrative meetings unless the assertion directly concerns a multidisciplinary clinical meeting about a patient's care.
  • Excludes generic communication, staffing, training or documentation deficiencies that are not directly tied to the operation of a multidisciplinary clinical meeting.
  • Excludes failures of a separately named clinical pathway or safety system where meeting operation is only an incidental component and the wider named concern provides the appropriate boundary.
  • Excludes inappropriate treatment, discharge or referral decisions where no deficiency in the multidisciplinary clinical meeting is identified.
Reports
33

Distinct published reports

Individual concerns
38

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
32

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 Care8
NHS England7
Essex Partnership University NHS Foundation Trust3
HM Prison and Probation Service3
Greater Manchester Mental Health NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
Ministry of Justice2
Recipient name withheld2
Alternative Futures Group Limited1
Birmingham and Solihull Mental Health NHS Foundation Trust1
British Transport Police1
Browning Street Surgery1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Colchester Hospital1

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. North London

    AI-generated summary

    Henry Marsh · 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

    Henry Marsh had multiple diagnoses and was under the care of the Home Treatment Team when he failed to attend a psychology appointment and was found unresponsive at home. The principal concern was that the Home Treatment Team had too many patients to manage effectively, making multidisciplinary meetings difficult; the inquest recorded suicide and polydrug intoxication as the medical cause of 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 hold effective multidisciplinary meetings

    Wider context from the report

    “The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi – disciplinary meetings when carrying such a large caseload. ”

    Source location

    Henry Marsh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. South Yorkshire (Eastern)

    AI-generated summary

    Peter John Hinchliffe · 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

    Peter John Hinchliffe, a fit 33-year-old man, died after collapsing while cycling on 11 September 2010; the inquest concluded that the cause of death was arrhythmogenic right ventricular cardiomyopathy, which was undiagnosed and untreated. The principal concerns were delays and differing approaches in investigating syncope, including delays in transferring investigations to the NHS, and inconsistent advice about exercise for young athletes in a recognised red-flag situation.

    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 multidisciplinary review of syncope investigations

    Wider context from the report

    “(3) Although Peter John Hinchliffe died approximately two weeks after transfer into the NHS system no further progress would have been made until after the MDT meeting in early October some 4 – 5 months after the incident of syncope. ”

    Source location

    Peter John Hinchliffe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Staffordshire South

    AI-generated summary

    Pauline Meredith · 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

    Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

    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 team meetings to discuss challenging patients

    Wider context from the report

    “(4) The lack of any team meetings with colleagues affording an opportunity to discuss challenging patients with colleagues. ”

    Source location

    Pauline Meredith · 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 structured criteria and a protocol for identifying complex patients who would benefit from discussion at clinical meetings.

    Verbatim wording from the response

    “2) The practice will endeavour in the future to identify complex patients who might benefit from discussion at clinical meetings. The practice is currently considering how to select patients for these”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 8 · response
    Published 10 January 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

    A practice meeting was not considered necessary because the patient appeared relatively stable and was receiving frequent support and supervision.

    Verbatim wording from the response

    “4. The lack of team meetings to discuss challenging patients: It is likely that I would have discussed Pauline and her anxiety and paranoid thinking with my General Practice colleagues in an informal way, as this often occurs in the course of General Practice when challenging problems are posed by patients, but I cannot recollect when this may have occurred. Informal discussions are not recorded in the notes.”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 6 · response
    Published 10 January 2014

    Open published response
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Data last updated 7 September 2026