Recurring concern

Failure to reliably communicate with and listen to families of mental health patients

First to latest report 11 Jul 2017 — 12 Jan 2026

Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
27

What this concern includes

Includes failures by mental-health assessment, treatment or related care services to contact, receive, listen to, understand or meaningfully consider safety-relevant information and concerns from a patient's family or friends, including failures to provide an accessible route for families to communicate concerns.

What is not included
  • Excludes family or carer involvement in care planning, discharge or treatment decisions when the specific concern is participation in the decision process rather than communication and listening about the patient's safety; that narrower concern has its own parent.
  • Excludes generic patient, family or inter-agency communication failures without a mental-health-care context.
  • Excludes failures to act on family information after it was reliably received and understood when the communication and listening process itself was adequate.
  • Excludes ordinary complaints or dissatisfaction without safety-relevant information about the patient's mental health, risks, deterioration or care.
  • Excludes communication with patients, professionals or agencies where family or friends are not the relevant source or recipient.

Reports and published responses 11 reports

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

  1. Leicester City and South Leicestershire

    AI-generated summary

    Margery Annie Astill · 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

    Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate and inaccurate communication with families of patients with mental health issues

    Wider context from the report

    “(2) Communication with family members was inadequate and inaccurate, the “named nurse” system was ineffective and therefore opportunities were lost to share information and to keep the family informed and involved. The failure of the Trust to engage with family members of patients with mental health issues have been raised in the past as a concern, and contrary to NICE Guidelines. ”

    Source location

    Margery Annie Astill · 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

    Deliver bespoke communication-skills training to nurses involved in the incidents.

    Verbatim wording from the response

    “The Trust acknowledges that the communication shared with the family following both the incidents was not an accurate description of the events which was later revealed in the CCTV footage. When the staff involved in the incidents provided Mrs Astill’s family with information regarding her falls, their form of communication did not convey the accuracy of the situation. In order to enhance the nursing staff with their communication skills, the nurses involved have subsequently attended a bespoke training course delivered by LOROS (Leicester Hospice Charity). This training course supports enhanced communication skills needed to support patients and relatives.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 11 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish the updated named-nurse information leaflet and checklist supporting accountability and timely communication with relatives and carers.

    Verbatim wording from the response

    “The service has approved the updated named nurse role and responsibility patient and carer information leaflet. Posters will be displayed on each ward defining the role of the named nurse to ensure that both patients and carers are clear about what to expect. A named nurse checklist has also been established to support Registered Nurses to carry out this role. This provides a clear accountability and audit trail whilst setting standards around timely communication with relatives and carers.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 11 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Display posters on each ward defining the named nurse’s role for patients and carers.

    Verbatim wording from the response

    “The service has approved the updated named nurse role and responsibility patient and carer information leaflet. Posters will be displayed on each ward defining the role of the named nurse to ensure that both patients and carers are clear about what to expect. A named nurse checklist has also been established to support Registered Nurses to carry out this role. This provides a clear accountability and audit trail whilst setting standards around timely communication with relatives and carers.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 11 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake a spot-check audit against NICE quality standards for hospital care involving older-person mental-health inpatient admissions.

    Verbatim wording from the response

    “The Trust further acknowledges the Coroner’s concern that it has not engaged with family members of patients with mental health issues which is contrary to Nice Guideline 136¹. With particular reference to mental health services for older people and inpatient admissions the service will be undertaking a spot check audit against the quality standard’s as set out for hospital care.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 11 July 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026