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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 33 reports

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

2 Jul2014
North London
Concerns raised1
1. Failure to hold effective multidisciplinary meetings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
25 Jun2014
South Yorkshire (Eastern)
Concerns raised1
1. Delays in multidisciplinary review of syncope investigations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
10 Jan2014
Staffordshire South
Concerns raised1
1. Lack of team meetings to discuss challenging patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Browning Street Surgery
Stated actions 1
1. Browning Street Surgery
  Develop structured criteria and a protocol for identifying complex patients who would benefit from discussion at clinical meetings.
Respondent positions 1
1. Browning Street Surgery
  A practice meeting was not considered necessary because the patient appeared relatively stable and was receiving frequent support and supervision.
  No action considered necessary
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