Recurring concern

Unsafe operation of multidisciplinary clinical meetings

First to latest report 10 Jan 2014 — 27 May 2026

Reports that mention this concern
33
Times this concern has been raised
38
Stated actions linked to this concern
32

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.

What is 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 and published responses 33 reports

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

  1. Staffordshire South

    AI-generated summary

    Thomas Paul Arthur JACKSON · 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

    Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

    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 recording of ward rounds or multi-disciplinary team meetings

    Wider context from the report

    “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · 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

    Inadequate patient participation in clinical meetings

    Wider context from the report

    “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · 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 appropriate personnel to attend clinical meetings

    Wider context from the report

    “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · 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

    Inadequate consideration of patient history before clinical meetings

    Wider context from the report

    “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Buckinghamshire

    AI-generated summary

    Lewis Daryl COLGAN · 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

    Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.

    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 robust process for alerting care teams to overdue CPA meetings

    Wider context from the report

    “(3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these. Evidence given during the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied. ”

    Source location

    Lewis Daryl COLGAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester West

    AI-generated summary

    William Myers · 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

    William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.

    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 undertake multidisciplinary case conference reassessment by a forensic psychiatrist

    Wider context from the report

    “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist. Neither of these took place and in consequence warning signs of impending or actual violence were not recognised. Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people. ”

    Source location

    William Myers · 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

    Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.

    Verbatim wording from the response

    “GMMH has ensured careful consideration is being given to the management of service users who go AWOL and the risk assessment process to be carried out prior to a multidisciplinary team discharging them.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 2 · response
    Published 14 March 2018

    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 forensic in-reach support for high-risk community patients, including timely advice, risk management and second opinions.

    Verbatim wording from the response

    “In addition we are working with colleagues in the Trust’s forensic services to develop in-reach forensic support in the management of high-risk/MoJ patients in the community, especially in areas such as Central West CMHT with a higher proportion of such patients. This will facilitate improved risk assessment and management, forensic opinion and case conferences.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 3 · response
    Published 14 March 2018

    Open published response

  4. Inner North London

    AI-generated summary

    Fallon Alphonsine ABBY · 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

    Fallon Alphonsine ABBY died by suicide after jumping from the balcony of her sixth-floor bedroom on 18 February 2017, following recent hospital attendances and discharge to a home treatment team. The report raised concerns that the Roman Ward team did not contact her social worker, meaning potentially valuable information was not shared and social-work support was not available on discharge.

    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 invite the social worker to ward rounds

    Wider context from the report

    “I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this. If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made. It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient. ”

    Source location

    Fallon Alphonsine ABBY · 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

    Work with admitted young people to negotiate their social worker’s involvement after informing the Leaving Care Team.

    Verbatim wording from the response

    “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

    Source location

    2017-0288-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 6 December 2017

    Open published response

  5. London (City)

    AI-generated summary

    SARAH LYNNE REED · 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

    Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

    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 holding Care Programme Approach meetings

    Wider context from the report

    “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable. The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception. In this case it was held after nine weeks. ”

    Source location

    SARAH LYNNE REED · Prevention of Future Deaths report
    Page 2 · 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

    Inadequate multidisciplinary participation in CPA meetings

    Wider context from the report

    “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner. ”

    Source location

    SARAH LYNNE REED · Prevention of Future Deaths report
    Page 2 · 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

    Inadequate quality and duration of CPA meetings

    Wider context from the report

    “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner. ”

    Source location

    SARAH LYNNE REED · 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

    Disseminate prison-specific guidance on CPA management requirements to all prison sites for comment.

    Verbatim wording from the response

    “We accept that in this case a CPA meeting should have been arranged sooner. Ms Reed’s mental health and social functioning had deteriorated to the degree that this should have been prioritised. Further, we recognise that a CPA meeting would have allowed more detailed discussion regarding medication management.”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 1 August 2017

    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

    Formally ratify the prison-specific CPA management guidance as a new policy by 1 October 2017.

    Verbatim wording from the response

    “As a result of this case CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 1 August 2017

    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

    CPA meetings are controlled by healthcare providers, so HMPPS would not necessarily be involved in them.

    Verbatim wording from the response

    “Care Programme Approach (CPA) Meetings Your next concern is about the scheduling of CPA meetings and attendance at them. Whilst you have directed this concern to HMPPS, CPA meetings are controlled by healthcare providers, and whilst we stand ready to assist where appropriate, we would not necessarily expect to be involved in these meetings. I am aware that the CNWL NHS Foundation Trust has responded to you separately on this point.”

    Source location

    2017-0208-Response-by-NOMS
    Page 3 · response
    Published 1 August 2017

    Open published response

  6. Preston and East Lancashire

    AI-generated summary

    Robert Cardwell · 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

    Robert Cardwell was under the care of a Home Treatment Team but was discharged after information about his missed appointment and request for a further appointment was not passed to the multidisciplinary team. He later expressed suicidal thoughts, described a plan to hang himself using a football scarf, and was found deceased at home on 29 September 2016 after hanging himself. Concerns included failures in communication, failure to discuss or follow up his request for an appointment, and inadequate record keeping during multidisciplinary team meetings.

    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 records during MDT meetings

    Wider context from the report

    “On the 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why he had not attended his appointment with the Psychiatrist that day. Mr Cardwell told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr Cardwell reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information would be passed to the MDT for their consideration the following day. Mr Cardwell wanted another appointment but he said it would have to be a home visit. Whilst Mr Cardwell was discussed at the MDT meeting on the 7th July and discharged, I found on the evidence that the message explaining his non-attendance and requesting a further appointment was not relayed to the MDT. Had that message been relayed to the MDT, I found that Mr Cardwell would have been offered a further appointment and would not have been discharged at that time. This failure in communication is a matter of concern. I am concerned about the process by which messages are relayed from service users to the MDT team. The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr Cardwell’s clinical record but these were not looked at during the course of the MDT meeting. ”

    Source location

    Robert Cardwell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. West Yorkshire (East)

    AI-generated summary

    Michaela Louise Thompson · 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

    Michaela Louise Thompson, who had a history of depression and regular suicidal thoughts, died by self-suspension at home on 1 December 2015. Concerns included inadequate documentation of multidisciplinary team meetings and the failure to record and promptly communicate a distressing telephone call to mental health services on the morning of her 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

    Inadequate documentation of multidisciplinary team meeting participants, outcomes and decisions

    Wider context from the report

    “(1) Michaela was the subject of two multi-disciplinary team meetings which were inadequately documented in the case notes. It should be clearly documented as to who was present and participating in such meetings. The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings. ”

    Source location

    Michaela Louise Thompson · 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 clear documentation of attendees, outcomes and decisions at multidisciplinary team meetings.

    Verbatim wording from the response

    “I am aware of Miss Thompson’s care and sad death therefore fully accept your requirement that there should be clear documentation as to who is present at multi-disciplinary team meetings along with clear documentation of any outcomes and decisions made. It is therefore something which we will of course put in place.”

    Source location

    2016-0392-Response-by-Leeds-and-York-NHS-Trust
    Page 1 · response
    Published 2 November 2016

    Open published response

  8. Leicester City and South Leicestershire

    AI-generated summary

    Ahmedreza Fathi · 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

    Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

    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 formalise multidisciplinary team meetings

    Wider context from the report

    “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  9. Nottinghamshire

    AI-generated summary

    Emma Carpenter · 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

    Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.

    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 school nurses to attend multidisciplinary meetings reliably

    Wider context from the report

    “3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses. ”

    Source location

    Emma Carpenter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Exeter & Greater Devon

    AI-generated summary

    George Christian Werb · 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

    George Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child psychiatric beds.

    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

    Ineffective multidisciplinary CPA meeting participation and communication

    Wider context from the report

    “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”

    Source location

    George Christian Werb · 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