Recurring concern

Unsafe coordination of shared care

Get email alerts

Request correction

First reported 1 May 2015•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the explicitly shared-care process, including unclear arrangements for documenting discussions, ineffective coordination between organisations or teams, and failures to communicate decisions or responsibilities across shared-care providers.

Not included

Excludes generic record-keeping failures not tied to an explicitly shared-care arrangement.
Excludes generic communication or multidisciplinary-discussion failures where shared care is not the named process.
Excludes failures confined to a single provider's assessment, treatment, staffing or resources without a shared-care coordination link.

Reports: 29
Individual concerns: 33
Date range: 2015–2026
Stated actions: 106

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.

Department of Health and Social Care10

NHS England6

Greater Manchester Mental Health NHS Foundation Trust2

NHS Greater Manchester Integrated Care Board2

NHS Northamptonshire Integrated Care Board2

Northamptonshire Healthcare NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

ADS (Addiction Dependency Solutions)1

Aneurin Bevan University LHB1

Ashfield House Surgery1

Bamford Grange Care Home1

Bolton Borough Council1

Brighton and Hove City Council1

Care Quality Commission1

Central and North West London 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.

15 Jun2026
West Sussex, Brighton and Hove
Concerns raised1
1. Fragmented information sharing and updating across healthcare providers
This report raised 3 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 5
1. Action
  Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
  Stated by NHS EnglandStated in progress
2. Action
  Facilitate collaborative sharing of patient data across care settings and geographic boundaries through Connecting Care Records.
  Stated by NHS EnglandStated completed
3. Action
  Provide the National Care Records Service for secure access to national patient information, including Summary Care Records and additional clinical information.
  Stated by NHS EnglandStated completed
1. Action
  Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
  Stated by NHS EnglandStated completed
2. Action
  Continue supporting interoperable shared care records and their development toward a joined-up Single Patient Record.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Responsibility for delivering shared care records sits with local Integrated Care Boards, based on local health and care needs and existing systems.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Referral routes, specialist service availability and information-sharing arrangements for ambulance clinicians are determined locally, not through a single national model.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Alex Ganski · 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

Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.

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
Fragmented information sharing and updating across healthcare providers
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · Prevention of Future Deaths report
Page 4 · 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
Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.

Verbatim wording from the response
“As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.”

Source location
Response from NHS England
Page 2 · response
Published 14 August 2026
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
Facilitate collaborative sharing of patient data across care settings and geographic boundaries through Connecting Care Records.

Verbatim wording from the response
“NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. This is discussed in more detail at point 3 below.”

Source location
Response from NHS England
Page 2 · response
Published 14 August 2026
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
Provide the National Care Records Service for secure access to national patient information, including Summary Care Records and additional clinical information.

Verbatim wording from the response
“The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. NHS England’s national digital team have advised that they would expect the local Mental Health Trust, and the local Drug and Alcohol treatment service to have access to patient’s summary care records via NCRS however utilisation of this resource will vary according to the local business processes. Further information on NCRS can be available here: National Care Records Service - NHS England Digital.”

Source location
Response from NHS England
Page 3 · response
Published 14 August 2026
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
Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.

Verbatim wording from the response
“NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.”

Source location
Response from NHS England
Page 4 · response
Published 14 August 2026
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
Continue supporting interoperable shared care records and their development toward a joined-up Single Patient Record.

Verbatim wording from the response
“The NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) in place, which provides, through different suppliers, a mechanism to access shared information between NHS Trusts and general practice. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record.”

Source location
Response from NHS England
Page 5 · response
Published 14 August 2026
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
Responsibility for delivering shared care records sits with local Integrated Care Boards, based on local health and care needs and existing systems.

Verbatim wording from the response
“Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care record are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England.”

Source location
Response from NHS England
Page 5 · response
Published 14 August 2026
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
Referral routes, specialist service availability and information-sharing arrangements for ambulance clinicians are determined locally, not through a single national model.

Verbatim wording from the response
“Where a patient consents, or where information sharing is otherwise justified for direct care, ambulance clinicians may contact other healthcare professionals or specialist services involved in a patient's care. However, the availability of referral routes, specialist services and information-sharing arrangements is determined locally and is not subject to a single nationally mandated model.”

Source location
Response from NHS England
Page 6 · response
Published 14 August 2026
Open published response
14 May2026
Coventry and Warwickshire
Concerns raised1
1. Failure to reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers
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 5
1. Action
  Implement a standard operating procedure defining communication, care, transfer, and return-to-ward responsibilities for patients transferred between mental health and acute services.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
2. Action
  Monitor compliance with the mental health–acute hospital memorandum of understanding monthly and reconsider review frequency after six months using performance and escalation data.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
3. Action
  Embed adherence to the transfer SOP within ward safety huddles, team handovers, and ward governance processes.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
1. Action
  Monitor compliance with communication and transfer processes through local governance, escalating themes and trends for organisational learning and continuous improvement.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
2. Action
  Establish and routinely monitor a memorandum of understanding and transfer process clarifying roles and sharing mental health care information for patients admitted to UHCW.
  Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completed
AI-generated summary

Natalia Violet Cestaro (known as “Tali”) · 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

Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.

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 reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers
Wider context from the report
“b) Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW) The evidence before the inquest disclosed limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare. While both organisations described mechanisms for access to advice and communication, there was relatively limited evidence of how these arrangements operate reliably, how compliance is assured, and how lapses are detected and addressed. This creates a risk that relevant mental health risks are not consistently carried through the acute admission. ”
Source location
Natalia Violet Cestaro (known as “Tali”) · 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
Implement a standard operating procedure defining communication, care, transfer, and return-to-ward responsibilities for patients transferred between mental health and acute services.

Verbatim wording from the response
“As part of the Safety Improvement Plan accompanying the Patient Safety Incident Investigation (PSII) report, an action was agreed to develop a Standard Operating Procedure (SOP) to provide guidance on communication, care and treatment arrangements for patients open to our services who are conveyed to University Hospital Coventry and Warwickshire (UHCW).”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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
Monitor compliance with the mental health–acute hospital memorandum of understanding monthly and reconsider review frequency after six months using performance and escalation data.

Verbatim wording from the response
“CWPT and UHCW are signatories to a Memorandum of Understanding (MoU) setting out arrangements for patients receiving inpatient mental health care who require physical healthcare treatment within a local acute hospital setting.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 3 · response
Published 17 July 2026
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
Embed adherence to the transfer SOP within ward safety huddles, team handovers, and ward governance processes.

Verbatim wording from the response
“Adherence to the SOP will be embedded within ward safety huddles, team handovers and ward governance processes.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 3 · response
Published 17 July 2026
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
Monitor compliance with communication and transfer processes through local governance, escalating themes and trends for organisational learning and continuous improvement.

Verbatim wording from the response
“In addition, compliance with the agreed communication and transfer processes will be monitored through local governance arrangements, providing assurance that expectations are understood, consistently applied and embedded within routine practice. Any themes or trends identified through this monitoring will be escalated through the Trust’s governance structures to support continuous improvement and organisational learning.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 3 · response
Published 17 July 2026
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
Establish and routinely monitor a memorandum of understanding and transfer process clarifying roles and sharing mental health care information for patients admitted to UHCW.

Verbatim wording from the response
“In response I can confirm that we have agreed the content of a Memorandum of Understanding (MOU) with CWPT (copy attached). The MOU seeks to bring clarity to roles and responsibilities for those circumstances in which an inpatient mental health patient may be admitted to UHCW for the treatment of a physical health condition.”

Source location
Response from University Hospitals Coventry and Warwickshire NHS Trust
Page 1 · response
Published 17 July 2026
Open published response
26 Mar2026
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of a designated lead with full oversight and authority over coordinated care
This report raised 3 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 1
1. Action
  Share the draft Personalised Care Framework with NHS organisations ahead of publication.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Alex Ganski · 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

Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

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 designated lead with full oversight and authority over coordinated care
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · 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
Share the draft Personalised Care Framework with NHS organisations ahead of publication.

Verbatim wording from the response
“The Personalised Care Framework also looks to improve continuity, clarity and safety by ensuring people experiencing serious mental illness have a named professional coordinating their care, a care plan that reflects their needs now, quicker re-access to support when things deteriorate, and more consistent standards of good care wherever they live. The Personalised Care Framework has been shared in draft with NHS organisations ahead of its expected publication.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
Open published response
27 Feb2026
East Sussex
Concerns raised1
1. Failure to coordinate ADHD prescribing between private providers and NHS GPs
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
  Highlight duplicate-prescription, medication-confusion, continuity-of-care and treatment-change communication risks to ADHD specialists and primary-care prescribers through ongoing programme work.
  Stated by NHS EnglandStated planned
2. Action
  Publish non-mandatory ADHD assessment and treatment guide prices and commissioning guidance setting expectations for assessment, data quality, governance, shared care and follow-up.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  The private ADHD provider considered its existing systems sufficient to ensure continuity of care and safer prescribing, requiring no process changes.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Louis Robert SAUNDERS · 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

Louis Robert Saunders, who had been diagnosed with ADHD and experienced suicidal ideation as a side effect of medication, travelled to the East Sussex coast on 9 October 2024 and was found dead at the base of a cliff the following morning. The principal concern was insufficient communication and continuity of care between the private ADHD clinic and NHS GP, resulting in concurrent prescribing of different ADHD medications and a risk of duplicate prescriptions or confusion about treatment.

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 coordinate ADHD prescribing between private providers and NHS GPs
Wider context from the report
“Whilst it is understood that Louis had stopped taking his medication due to a perceived increase in suicidal ideation, and no medication was found in his system following his death, the evidence identified that he was being prescribed ADHD medication by both his NHS GP and the private ADHD clinic. Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest. After Louis’ ADHD treatment was transferred to his GP, the plan was for the surgery to continue issuing his medication. Accordingly, on 6 November 2023, the surgery issued a prescription for lisdexamfetamine ([REDACTED]). However, Louis had attended an appointment at the ADHD clinic the previous day, on 5 November 2023, and the clinic’s notes record that he was to continue on Dexamphetamine ([REDACTED]). Although the medications have similar names, they are distinct drugs with different dosing requirements. Effective management and titration are understood to be essential to ensure therapeutic benefit and limit adverse effects. The concern that has arisen relates to continuity of care between private providers and the NHS once a patient has been diagnosed with ADHD, commenced on medication, and subsequently transferred to GP care. In Louis’ case, communication between the private sector and the NHS was insufficiently clear, and the situation became more complex when he continued to be seen by both the ADHD clinic and his GP. This created opportunities for key information to be missed. Although medication was not directly implicated in Louis’ death, there remains a risk that a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take. Such scenarios may pose a risk of future deaths. As increasing numbers of patients are receiving ADHD diagnoses and commencing treatment in the private sector due to long NHS waiting times, I am concerned about the robustness of current processes to ensure safe and continuous care following transfer to a GP. ”
Source location
Louis Robert SAUNDERS · 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
Highlight duplicate-prescription, medication-confusion, continuity-of-care and treatment-change communication risks to ADHD specialists and primary-care prescribers through ongoing programme work.

Verbatim wording from the response
“I have fed your concerns back to NHS England’s National ADHD Programme and Primary Care Teams, who will ensure that the risks you have raised of duplicate prescriptions and confusion between current and previous medication regimes, and actions you have identified, including the need for continuity of care and timely and effective communication of treatment changes, are highlighted to both specialist providers and primary care prescribers wherever possible in their ongoing work.”

Source location
2026-0130 - Response from NHS England
Page 2 · response
Published 10 March 2026
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
Publish non-mandatory ADHD assessment and treatment guide prices and commissioning guidance setting expectations for assessment, data quality, governance, shared care and follow-up.

Verbatim wording from the response
“NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD. We recently published non-mandatory guide prices for ADHD assessments and treatment pathways, alongside detailed commissioning guidance, that will set clear expectations for assessment standards, data quality, clinical governance, shared care and follow-up.”

Source location
2026-0130 - Response from NHS England
Page 2 · response
Published 10 March 2026
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
The private ADHD provider considered its existing systems sufficient to ensure continuity of care and safer prescribing, requiring no process changes.

Verbatim wording from the response
“The Region have liaised with the private ADHD clinic who have advised that they have held a formal preventing future deaths review meeting for this case. The result of the review was that they did not identify any deficiencies in their processes, nor any changes required to their current clinical practice. They highlighted their current systems ensure continuity of care and safer prescribing which included that following every clinical interaction, including titration, medication reviews, and shared care reviews, detailed written correspondence is issued to the patient’s GP to ensure continuity, transparency, and clarity of care. They clarified that they do not initiate medication without first obtaining a Summary Care Record or equivalent clinical information from the patient’s GP.”

Source location
2026-0130 - Response from NHS England
Page 3 · response
Published 10 March 2026
Open published response
22 Dec2025
Northamptonshire
Concerns raised1
1. Failure to communicate medication changes between private and NHS psychiatric providers
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

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.

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 communicate medication changes between private and NHS psychiatric providers
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...". It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Source location
Wendy Siobhan EYLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Dec2025
Northamptonshire
Concerns raised1
1. Failure to communicate medication changes between private and NHS psychiatric providers
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

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between 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
Failure to communicate medication changes between private and NHS psychiatric providers
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Source location
Wendy Siobhan EYLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Nov2025
Manchester South
Concerns raised1
1. Failure to maintain a clear, effective and documented communication system for wound management care plans
This report raised 3 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 7
1. Action
  Require documentation of all hospital and community-team calls, unsuccessful attempts and mitigation for missing treatment plans.
  Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completed
2. Action
  Record hospital admission and discharge-planning calls in Nourish with contact details, timing and required follow-up.
  Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completed
3. Action
  Require referrals to tissue-viability nurses or community teams within 24 hours, including photographs and current treatment-plan information.
  Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completed
1. Action
  Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.
  Stated by Stockport NHS Foundation TrustStated planned
3. Action
  Establish a task and finish group to improve discharge checklist quality and information.
  Stated by Stockport NHS Foundation TrustStated completed
4. Action
  Improve the quality and information included in the discharge checklist through the task and finish group.
  Stated by Stockport NHS Foundation TrustStated planned
AI-generated summary

Richard Charles Worswick · 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

Richard Charles Worswick, who had Parkinson’s disease, frailty and complex health needs, developed an infected spinal wound and died from sepsis at Stepping Hill Hospital on 19 May 2025. The principal concerns were unclear communication and documentation of the wound-care plan between the hospital and care home, together with unclear escalation arrangements and limited documentation of concerns and escalation attempts.

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 maintain a clear, effective and documented communication system for wound management care plans
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
Source location
Richard Charles Worswick · 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
Require documentation of all hospital and community-team calls, unsuccessful attempts and mitigation for missing treatment plans.

Verbatim wording from the response
“As a result of the Inquest findings and I can confirm that the following action has been taken to ensure proper adherence to the existing policies and procedures going forwards particularly with regard to the re-admission of residents to the Home from hospital and arrangements for monitoring of wound care and clinical observations:”

Source location
Response from Bamford Grange Care Home
Page 2 · response
Published 11 November 2025
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
Record hospital admission and discharge-planning calls in Nourish with contact details, timing and required follow-up.

Verbatim wording from the response
“As a result of the Inquest findings and I can confirm that the following action has been taken to ensure proper adherence to the existing policies and procedures going forwards particularly with regard to the re-admission of residents to the Home from hospital and arrangements for monitoring of wound care and clinical observations:”

Source location
Response from Bamford Grange Care Home
Page 2 · response
Published 11 November 2025
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
Require referrals to tissue-viability nurses or community teams within 24 hours, including photographs and current treatment-plan information.

Verbatim wording from the response
“As a result of the Inquest findings and I can confirm that the following action has been taken to ensure proper adherence to the existing policies and procedures going forwards particularly with regard to the re-admission of residents to the Home from hospital and arrangements for monitoring of wound care and clinical observations:”

Source location
Response from Bamford Grange Care Home
Page 2 · response
Published 11 November 2025
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
Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.

Verbatim wording from the response
“The Trust issued a Trust wide alert on 20 November 2025 in relation to Transfer of Care documentation and action required from all areas to ensure two copies of the documentation are printed; one to go with the patient to the care home and one to be placed in the patient’s records. Please find a copy of the Trust wide alert attached.”

Source location
Response from Stockport NHS Foundation Trust
Page 1 · response
Published 11 November 2025
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
Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.

Verbatim wording from the response
“In order to provide assurance that this practice is fully embedded across the Trust, a Trust wide audit will take place. Five patient discharges to other care providers will be audited per ward for discharges which have taken place in December. The audit will be carried out in the first two weeks of February 2026 and will check that there is a copy of the Transfer of Care documentation within the patient’s record.”

Source location
Response from Stockport NHS Foundation Trust
Page 1 · response
Published 11 November 2025
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
Establish a task and finish group to improve discharge checklist quality and information.

Verbatim wording from the response
“During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.”

Source location
Response from Stockport NHS Foundation Trust
Page 2 · response
Published 11 November 2025
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
Improve the quality and information included in the discharge checklist through the task and finish group.

Verbatim wording from the response
“During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.”

Source location
Response from Stockport NHS Foundation Trust
Page 2 · response
Published 11 November 2025
Open published response
24 Oct2025
Nottinghamshire
Concerns raised1
1. Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
This report raised 11 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
  Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
2. Action
  Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
AI-generated summary

Sophie Louise TOWLE · 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

Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.

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 embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
Wider context from the report
“1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body. There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult. If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team. In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue. ”
Source location
Sophie Louise TOWLE · 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
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.

Verbatim wording from the response
“Staff at Nottinghamshire Healthcare Foundation Trust (NHFT) and Sherwood Forest Hospital Trust (SFHT) have collaborated on creating a joint management policy that provides guidance to staff on the management of patients who have inserted a foreign body. This includes the recommendation of joint meetings to support joined up collaborative care for patients requiring support from both services. This is being trialled for three months, and the impact of its use will be reviewed.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 1 · response
Published 31 October 2025
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
Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.

Verbatim wording from the response
“Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately inserted foreign bodies, as initially presented to HM Coroner, was undertaken. This review was conducted with the support and oversight of the Governance Support Unit to ensure rigorous examination and improvement of the procedure.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 31 October 2025
Open published response
6 Oct2025
Gwent
Concerns raised1
1. Failure of communication between hospital and community dietetic teams
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 16
1. Action
  Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.
  Stated by Velindre NHS TrustStated completed
2. Action
  Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.
  Stated by Velindre NHS TrustStated in progress
3. Action
  Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.
  Stated by Velindre NHS TrustStated in progress
1. Action
  Audit the multidisciplinary team checklist and share learning through quality and safety governance.
  Stated by Velindre NHS TrustStated planned
2. Action
  Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.
  Stated by Velindre NHS TrustStated planned
3. Action
  Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.
  Stated by Velindre NHS TrustStated in progress
4. Action
  Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.
  Stated by Velindre NHS TrustStated planned
5. Action
  Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.
  Stated by Velindre NHS TrustStated completed
6. Action
  Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.
  Stated by Velindre NHS TrustStated planned
7. Action
  Develop a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
  Stated by Aneurin Bevan University LHBStated in progress
8. Action
  Provide interim cross-organisational read-only clinical-record access for relevant dietitians.
  Stated by Aneurin Bevan University LHBStatus at response
9. Action
  Grant appropriate ABUHB dietitians access to WCP clinical records.
  Stated by Aneurin Bevan University LHBStated planned
10. Action
  Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
  Stated by Aneurin Bevan University LHBStated planned
11. Action
  Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
  Stated by Aneurin Bevan University LHBStated planned
12. Action
  Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
  Stated by Aneurin Bevan University LHBStated planned
13. Action
  Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
  Stated by Aneurin Bevan University LHBStated in progress
Respondent positions 1
1. Position
  The actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.
  Stated by Velindre NHS TrustExisting arrangements considered sufficient
AI-generated summary

Steven Paul TURZYNSKI · 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

Steven Paul Turzynski, who had lung cancer and a history of treated oropharyngeal cancer, died from the effects of lung cancer on 29 July 2024. The report identified very limited communication between the two dietetic teams, lack of shared records, and inadequate nutritional assessment, with significant undernutrition by the time of his 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 of communication between hospital and community dietetic teams
Wider context from the report
“Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. ”
Source location
Steven Paul TURZYNSKI · 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
Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.

Verbatim wording from the response
“To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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
Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.

Verbatim wording from the response
“• Quarterly joint dietetic meetings with ABUHB to support shared learning and early escalation of any potential risks or issues”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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
Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.

Verbatim wording from the response
“3. Safety action description (SMART): To improve multi-disciplinary communication and working processes between VCS and ABUHB by introducing a shared communication protocol/checklist and establishing when urgent joint MDT meetings are required.”

Source location
Response from Velindre University NHS Trust
Page 7 · response
Published 9 October 2025
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
Audit the multidisciplinary team checklist and share learning through quality and safety governance.

Verbatim wording from the response
“Proposed action: Draft MDT checklist will go through the internal ratification process and be implemented. To ensure the checklist is robust and fit for purpose, it is necessary to undertake an audit of the checklist. This will be recorded and tracked on our internal audit governance system (AMaT) and will be reported through internal governance at quality and safety board meetings.”

Source location
Response from Velindre University NHS Trust
Page 7 · response
Published 9 October 2025
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
Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.

Verbatim wording from the response
“• Development of an interim shared care transfer document until the All-Wales standard is formally approved”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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
Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.

Verbatim wording from the response
“• Active engagement with the Welsh Dietetic Leaders Advisory Group (WDLAG) to strengthen cross-boundary referral processes”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
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
Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.

Verbatim wording from the response
“5. To ensure replication of safety action #1,3 &4 above, across all VCS commissioned health boards in Wales.”

Source location
Response from Velindre University NHS Trust
Page 9 · response
Published 9 October 2025
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
Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.

Verbatim wording from the response
“1. Safety action description (SMART): To ensure all Dietitians have access to Clinical WorkStation (CWS) to enable full notes to be accessible between VCS and ABUHB.”

Source location
Response from Velindre University NHS Trust
Page 10 · response
Published 9 October 2025
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
Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.

Verbatim wording from the response
“3. Safety action description (SMART): To ensure replication of safety action #1 & 2 above, across all VCS commissioned health boards in Wales.”

Source location
Response from Velindre University NHS Trust
Page 11 · response
Published 9 October 2025
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 a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.

Verbatim wording from the response
“Assurance Statement Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) recognise the coroner’s concern that inadequate communication between each organisations’ dietetic teams contributed to suboptimal nutritional management. Both organisations are committed to strengthening the safety and consistency of information exchange for all patients whose care is transferred across organisational boundaries.”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 9 October 2025
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
Provide interim cross-organisational read-only clinical-record access for relevant dietitians.

Verbatim wording from the response
“• Shared Access to Clinical Records: Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 9 October 2025
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
Grant appropriate ABUHB dietitians access to WCP clinical records.

Verbatim wording from the response
“• Shared Access to Clinical Records: Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 9 October 2025
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
Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.

Verbatim wording from the response
“• Multidisciplinary Interface Meetings: Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss and review any shared oncology cases, clinical incidents, resolve communication issues, and identify opportunities for process improvement”

Source location
Response from Aneurin Bevan University Health Board
Page 3 · response
Published 9 October 2025
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 annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.

Verbatim wording from the response
“• Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety assurance group”

Source location
Response from Aneurin Bevan University Health Board
Page 3 · response
Published 9 October 2025
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
Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.

Verbatim wording from the response
“• Exception and Learning Reporting: Any deficiencies or recurrent communication failures will be logged through Datix and reviewed at joint governance meetings. Themes and learning will be fed into professional development sessions.”

Source location
Response from Aneurin Bevan University Health Board
Page 4 · response
Published 9 October 2025
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
Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.

Verbatim wording from the response
“At a system level, the Health Board and VUHNHST have committed to working in close partnership to maintain and monitor these improvements. Regular joint meetings between both organisations will review progress against the action plan, share emerging learning, and resolve any cross-boundary issues in real time.”

Source location
Response from Aneurin Bevan University Health Board
Page 4 · response
Published 9 October 2025
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
The actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.

Verbatim wording from the response
“I hope that this response provides you with the assurance required that the action we have taken is robust enough to prevent future deaths related to dietetic support and provision.”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
Open published response
15 Jul2025
Inner North London
Concerns raised1
1. Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Raise Alfie’s case with Neonatal Operational Delivery Networks and Regional maternity teams.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  Direct control over how healthcare staff record clinical communications lies outside the organisation’s authority as a membership body.
  Stated by Royal College of Paediatrics and Child HealthOutside remit
1. Position
  Trusts are responsible for ensuring effective recording and access processes where digital infrastructure is unavailable.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Alfie Lydon · 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

Alfie Lydon was admitted to hospital after being found profoundly unwell at home, transferred for intensive care, and died from the consequences of a viral infection. Before admission, his parents had raised concerns about his feeding and increasing lethargy, and discussions between midwives and the neonatal team were not consistently documented. The report raised concern that inadequate, contemporaneous documentation of discussions between community and hospital teams could affect continuity and escalation of care and result in future deaths in similar circumstances.

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 maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams
Wider context from the report
“1. I heard evidence that the vast majority of hospital Trusts do not have processes in place to document external calls from midwives to hospital teams. Concerns were raised that this can result in a lack of continuity and escalation of care, particularly with regards to parental concerns. The hospital Trust involved has taken steps to document such calls now but this is undertaken on paper, which is subsequently uploaded to the hospital records. They plan to implement an electronic solution but not for some time. There is a concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Given that this is not simply a local issue, this concern warrants raising at a national level. ”
Source location
Alfie Lydon · 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
Raise Alfie’s case with Neonatal Operational Delivery Networks and Regional maternity teams.

Verbatim wording from the response
“Alfie’s case will be raised with the Neonatal Operational Delivery Networks and Regional maternity teams, with the expectation that they subsequently cascade to all maternity and neonatal units the importance of documenting such consultations.”

Source location
Response from NHS England
Page 2 · response
Published 17 July 2025
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
Direct control over how healthcare staff record clinical communications lies outside the organisation’s authority as a membership body.

Verbatim wording from the response
“As a membership organisation we have no direct control over the mechanism(s) by which healthcare staff record their clinical communications. Our sphere of influence lies in nudging change at national level. Currently, there is a lack of legislation and guidance on exactly what information, when and how it should be shared between agencies. In practice, our members (paediatricians) have reported difficulties in exchanging information, which may be a result of poor communication between professionals and/or a lack of interoperable information systems available to effectively share information. Use of the NHS number as a single unique identifier for children will overcome these barriers and enable information to be shared more easily between agencies and services.”

Source location
Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 17 July 2025
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
Trusts are responsible for ensuring effective recording and access processes where digital infrastructure is unavailable.

Verbatim wording from the response
“With regard to documenting communication between community midwives and staff working on acute sites, this would be a standard expectation in the provision of care for both those making and those receiving the calls. Both staff groups will typically utilise the relevant Trust’s Electronic Patient Record (EPR) system for either community midwifery services or hospital maternity / neonatal services, depending on which staff groups on the acute site are involved. This should allow them to record information directly within the patient’s record, which should be accessible to all system users regardless of setting. This is on the provision that the maternity service has the necessary digital infrastructure, including capabilities for offline working when in the community.”

Source location
Response from NHS England
Page 1 · response
Published 17 July 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Fragmented information sharing and updating across healthcare providers

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.5

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 reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers

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.5

Concerns raised1

Lack of a designated lead with full oversight and authority over coordinated care

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.1

Concerns raised1

Failure to coordinate ADHD prescribing between private providers and NHS GPs

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

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

Concerns raised1

Failure to communicate medication changes between private and NHS psychiatric providers

Concerns raised1

Failure to communicate medication changes between private and NHS psychiatric providers

Concerns raised1

Failure to maintain a clear, effective and documented communication system for wound management care plans

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.7

Actions described in response 5

Respondent positions 2

Actions described in response 5

Actions described in response 1

Actions described in response 2

Respondent positions 1

Actions described in response 7