Recurring concern

Failure to reliably respond to patient and carer communications

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First reported 13 Feb 2014•Latest report 30 Jun 2025

Definition

What this concern includes

Includes failures of processes for receiving, viewing, acknowledging, triaging, responding to or escalating direct patient and carer communications to clinicians or clinical services, including phone calls, messages and emails, where the failure can delay advice, assessment, follow-up or other necessary care.

Not included

Excludes generic inter-professional communication, handover or information-sharing failures where patients or carers are not the relevant communicators or recipients.
Excludes appointment, referral, emergency-call or crisis-service access failures when the specific unsafe condition is not failure to respond to a direct patient or carer communication.
Excludes failures limited to the content or clinical quality of a response after the communication was reliably received and answered.
Excludes generic staffing, workload, training, documentation or technology deficiencies unless they directly cause unreliable handling of direct patient or carer communications.

Reports: 4
Individual concerns: 5
Date range: 2014–2025
Stated actions: 5

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 England2

Barts Health NHS Trust1

Cygnet Health Care Limited1

Department of Health and Social Care1

Ealing RISE1

Guy'S and St Thomas' NHS Foundation Trust1

Kent and Medway Mental Health NHS Trust1

Mid and South Essex 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.

30 Jun2025
West London
Concerns raised1
1. Lack of an effective confidentiality-compliant channel for receiving communications when consent is withdrawn
This report raised 2 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

Ella Colette La-India DAVID-FONG · 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

Ella Colette La-India DAVID-FONG was found collapsed outside her home and died in hospital later the same day after taking illicit drugs that resulted in an unintentional overdose. The principal concern was that, when Ella withdrew consent for information to be shared with her family, agencies could not use information held by her family to assist her care. The report also identified inadequate information for families and carers about consent, confidentiality, and how to communicate concerns when consent is withdrawn.

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 an effective confidentiality-compliant channel for receiving communications when consent is withdrawn
Wider context from the report
“Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective therapeutic relationships as well as required under the legal framework. (1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue. The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn. Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing. ”
Source location
Ella Colette La-India DAVID-FONG · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Feb2024
Essex
Concerns raised2
1. Failure to respond to patient communications requiring medication clarification
2. Failure to answer patient and carer communications in a timely manner
This report raised 13 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.
Actions described in response 2
1. Action
  Increase neurology administrative support and obtain additional funding for administrative staff in the Multiple Sclerosis service.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
2. Action
  Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
  Stated by NHS EnglandStated planned
AI-generated summary

Chloe Anne Tapp · 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

Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

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 respond to patient communications requiring medication clarification
Wider context from the report
“Phone calls and messages left with the neurology department went unanswered, at a time when clarity over the tapering regime was needed. ”
Source location
Chloe Anne Tapp · Prevention of Future Deaths report
Page 3 · 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 to answer patient and carer communications in a timely manner
Wider context from the report
“The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including: o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department o Substantial and unsafe backlogs for first and follow up appointments o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries. o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results. ”
Source location
Chloe Anne Tapp · Prevention of Future Deaths report
Page 3 · 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
Increase neurology administrative support and obtain additional funding for administrative staff in the Multiple Sclerosis service.

Verbatim wording from the response
“We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.”

Source location
Response from Mid and South Essex NHS
Page 4 · response
Published 6 March 2024
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
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.

Verbatim wording from the response
“Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.”

Source location
Response from NHS England
Page 2 · response
Published 6 March 2024
Open published response
28 Nov2017
Inner South London
Concerns raised1
1. Failure to view, acknowledge and respond to direct-access patient communications
This report raised 2 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.
Actions described in response 3
1. Action
  Draw up Trust-wide guidance on clinicians’ responsibilities for email communication with patients.
  Stated by Barts Health NHS TrustStated in progress
2. Action
  Explore current practice for email correspondence between clinicians and patients.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated in progress
3. Action
  Consider producing local clinician guidance on patient email and text communication based on NHS England guidance.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Concerns about an individual clinician’s conduct should be referred to the General Medical Council as regulator.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Mr Harold Chapman · 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

Mr Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.

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 view, acknowledge and respond to direct-access patient communications
Wider context from the report
“During the course of the inquest, the evidence revealed during his dealings with the Barts NHS Trust and, more specifically the lead consultants, emails were passed by Mr Chapman to the consultants. It became clear during the inquest that those emails were often not viewed and/or acted upon and as a result no response was received by the patient. It is fully appreciated that consultants are busy with their clinical responsibilities covering wards, clinics and on-calls. However, if contact details are provided for ‘direct access’ to individual doctors/consultants, it seems obligatory that those should be viewed, acknowledged and patients responded to. Patient contact with medical professionals, not just hospital related, is an important part of modern medical practice. Whilst this is a huge task, it would seem possible to come up with either National or local guidelines in respect of the use of all forms of communication between patients and their clinician (covering phone and emails). ”
Source location
Mr Harold Chapman · 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
Draw up Trust-wide guidance on clinicians’ responsibilities for email communication with patients.

Verbatim wording from the response
“More widely, clear guidance is needed for all clinicians on their responsibilities regarding email communication with patients. Trust wide guidelines are being drawn up, working to the following principles:”

Source location
2017-0377-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 12 February 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
Explore current practice for email correspondence between clinicians and patients.

Verbatim wording from the response
“RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and patients and, pending production of any national guidelines from the Department of Health, will consider production of local guidance to clinicians based on the NHS England Accessible Information Standard ‘Using email and text messaging for communicating with patients- guidance from the Information Governance team at NHS England’ (May 2016).”

Source location
2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
Page 2 · response
Published 12 February 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
Consider producing local clinician guidance on patient email and text communication based on NHS England guidance.

Verbatim wording from the response
“RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and patients and, pending production of any national guidelines from the Department of Health, will consider production of local guidance to clinicians based on the NHS England Accessible Information Standard ‘Using email and text messaging for communicating with patients- guidance from the Information Governance team at NHS England’ (May 2016).”

Source location
2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
Page 2 · response
Published 12 February 2018
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
Concerns about an individual clinician’s conduct should be referred to the General Medical Council as regulator.

Verbatim wording from the response
“I hope this information is helpful and provides assurance that there is guidance available to clinicians in this area. Where there are concerns about the conduct of an individual clinician, these should be brought to the attention of the GMC as regulator.”

Source location
2017-0377-Response-by-Department-of-Health
Page 5 · response
Published 12 February 2018
Open published response
13 Feb2014
Inner West London
Concerns raised1
1. Insufficient staffing to answer patients’ phone calls
This report raised 9 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

Lisa Marie Inkin · 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

Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.

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
Insufficient staffing to answer patients’ phone calls
Wider context from the report
“7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to patients. ”
Source location
Lisa Marie Inkin · 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

Lack of an effective confidentiality-compliant channel for receiving communications when consent is withdrawn

Concerns raised2

Failure to respond to patient communications requiring medication clarification

Failure to answer patient and carer communications in a timely manner

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to view, acknowledge and respond to direct-access patient communications

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Insufficient staffing to answer patients’ phone calls

Actions described in response 2

Actions described in response 3

Respondent positions 1