Recurring concern

Failure to maintain follow-up of patients who disengage from care

Get email alerts

Request correction

First reported 23 Jul 2013•Latest report 1 Oct 2025

Definition

What this concern includes

Includes failures of a patient follow-up or contact process involving non-compliance, non-contact, disengagement or loss to follow-up, including failures to initiate further contact, escalate concerns or maintain continuity across services.

Not included

Excludes routine delays in follow-up where patient disengagement or non-contact is not material to the concern.
Excludes failures concerning a specific diagnostic, treatment or appointment process unless the report identifies loss of patient follow-up as the shared unsafe condition.
Excludes generic staffing, training, documentation or governance deficiencies not explicitly tied to maintaining follow-up of disengaged patients.

Reports: 23
Individual concerns: 23
Date range: 2013–2025
Stated actions: 29

Reports 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.

NHS England3

Care Quality Commission2

Essex Partnership University NHS Foundation Trust2

Midlands Partnership University NHS Foundation Trust2

Avenue House Nursing and Care Home1

Bexley Medical Group1

Bury Borough Council1

CAMHS East – Cross Street Clinic1

Care UK1

City Health Care Partnership CIC1

Community Mental Health Recovery Services (Surrey and Borders Partnership)1

CRG Medical Services1

Digital Health and Care Wales1

Droylsden Road Family Practice1

Gloucestershire Health and Care NHS Foundation Trust1

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.

12 May2014
Inner West London
Concerns raised1
1. Failure to contact family or next of kin when a patient who previously declined contact disengages from psychiatric services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Keiran Michael John Toman · 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

Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and 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 contact family or next of kin when a patient who previously declined contact disengages from psychiatric services
Wider context from the report
“(4) That where decisions are taken by psychiatric staff not to contact family in line with a patients wishes in order to try and keep that patient engaged with services, that contact is still not made to the family or next of kin even when such a patient disengages from the psychiatric services. ”
Source location
Keiran Michael John Toman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 May2014
Inner South London
Concerns raised1
1. Failure to ensure reliable communication pathways for follow-up
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.
  Stated by South London and Maudsley NHS Foundation TrustDisputes the concern
1. Position
  Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.
  Stated by South London and Maudsley NHS Foundation TrustUnable to act
AI-generated summary

Gary Richards · 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

Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

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 reliable communication pathways for follow-up
Wider context from the report
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”
Source location
Gary Richards · Prevention of Future Deaths report
Page 1 · 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
Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.

Verbatim wording from the response
“A further review of Mr Richards’ records indicates that when he was seen in the outpatient clinic in June, the service was aware of his mobile phone number. In fact, he had been called the day before by a social worker at the community team and asked to attend the outpatient appointment on 14 June as his GP had been concerned that he had again reported suicidal ideation.”

Source location
2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 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
Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.

Verbatim wording from the response
“She tried, using the number on file, but it was unobtainable. There was no other way of making contact with Mr Richards, so she left a message at the A&E department asking him to make contact with her should he re-present as he had booked an appointment to see her on 2 October.”

Source location
2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 3 · response
Published 9 May 2014
Open published response
23 Jul2013
Surrey
Concerns raised1
1. Failure to report patient non-response to operatives
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stanley Charles Dodson · 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

Stanley Charles Dodson was found dead at his home on 1 October 2012 after contacting a community alarm operative to request a doctor and the on-call doctor was unable to reach him by telephone. The concern was that the doctor’s unsuccessful attempts to contact him were not reported back to the operative, preventing consideration of further action to contact him.

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 report patient non-response to operatives
Wider context from the report
“Although the Doctor made several attempts to directly contact Mr Dodson and left a telephone message for him, these difficulties were not reported back to the operative to enable consideration of further action to contact him. I would be grateful if you could consider the appropriateness of extending your existing protocols to requirements that locum doctors should inform the operatives in the event of the non response of patients. ”
Source location
Stanley Charles Dodson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to contact family or next of kin when a patient who previously declined contact disengages from psychiatric services

Concerns raised1

Failure to ensure reliable communication pathways for follow-up

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to report patient non-response to operatives

Respondent positions 2