Recurring concern

Unreliable admission assessment of patients

First to latest report 30 Jul 2013 — 27 May 2026

Reports that mention this concern
27
Times this concern has been raised
28
Stated actions linked to this concern
18

What this concern includes

Includes failures of the admission or immediate receiving-assessment process, including omitted or delayed assessment, failure to complete required assessment components, failure to reconcile relevant pre-admission information, and failure to make necessary clinical information available to admission clinicians.

What is not included
  • Excludes failures limited to maintaining or retrieving clinical records when no admission-assessment impact is identified.
  • Excludes pre-discharge, post-discharge, outpatient or routine ongoing assessments that are not part of admission or immediate receiving assessment.
  • Excludes condition-specific assessment pathways, such as VTE, bowel-obstruction or mental-health assessment, when that named pathway supplies the more specific supported concern.
  • Excludes failures occurring after an adequate admission assessment where the problem is subsequent monitoring, treatment, escalation or care planning.

Reports and published responses 27 reports

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

  1. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

    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 incorporate relevant previous restraint and trauma history into admission care

    Wider context from the report

    “2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission. ”

    Source location

    Abigail Louise SMITH · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Somerset

    AI-generated summary

    Edwin Everett Milne Price · 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

    Edwin Everett Milne Price, who lived in a nursing home and required hoisting for transfers, was admitted to hospital with diabetic ketoacidosis and fell out of bed the following day. He sustained a fractured humerus and a retroperitoneal bleed, which was recorded as the cause of his death. The principal concerns were that his falls risk assessment was not completed within 24 hours, relevant information was not obtained from the nursing home, and mitigation measures were not put in place.

    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 complete falls risk assessments within the first 24 hours of ward admission

    Wider context from the report

    “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward. 2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate. 3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed. 4. The lack of a risk assessment meant that mitigation measures were not in place. 5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death. 6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes. ”

    Source location

    Edwin Everett Milne Price · 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 falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.

    Verbatim wording from the response

    “In April 2023 Somerset NHS Foundation Trust (SFT) and Yeovil District Hospital (YDH) merged organisations to become one Somerset NHS Foundation Trust, and there has been a period, ongoing, where there has been alignment of policies and guidance across the new Somerset NHS FT organisation. At the time of Mr Price’s fall, colleagues in YDH were still working to the legacy policy in place which did not have a time frame in which a Falls Risk assessment was to be completed. The legacy Somerset FT policy and the newly merged one organisational Somerset FT policy both state that an individual must have a Falls Risk Assessment within 12 hours of admission to an inpatient ward, and that this is reviewed if the person moves to another inpatient ward / has a fall / their condition changes.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 1 · response
    Published 2 September 2025

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    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 falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.

    Verbatim wording from the response

    “The Deputy Associate Director of Patient Care (ADPC), Matron and Ward Managers are monitoring compliance with the completion of the falls risk assessments and although these are audited monthly through our Core Nursing Metrics, additional spot audits are also being undertaken. These have shown an increase in compliance, however further strengthening in this area is required to ensure an embedded and sustained process of compliance with the expected 12-hour target.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 1 · response
    Published 2 September 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 an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.

    Verbatim wording from the response

    “In response to this incident, our acute medical unit (AMU) has introduced a checklist to be completed on admission which involves contacting the patient’s family, care home or community hospital to gather more detailed information about the patient (see appendix 1). The guidance on the patient’s baseline function and the usual mitigations that are in place in their usual residence to reduce the risk of harm”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 2 September 2025

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    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 Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.

    Verbatim wording from the response

    “We acknowledge also that an appropriate risk assessment on admission would have assisted us to identify Mr Price’s risk more clearly and put sufficient mitigations in place to reduce the risk of harm to him. In addition to the risk assessment, to help us reduce risk to patients, we use an Intentional Rounding tool to assist with care planning and patient involvement. At a minimum a patient is seen two hourly and engaged with, this is in addition to physical observations. From our recent reviews, including learning from Mr Price’s case, it has become clear that there has been a lack of clarity around the purpose and process associated with the meaningful delivery of Intentional Rounding across the Trust.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 2 September 2025

    Open published response

  3. Inner West London

    AI-generated summary

    Junior George Powell · 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

    Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in medical assessment and diagnosis of conditions requiring urgent treatment

    Wider context from the report

    “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such patients. ”

    Source location

    Junior George Powell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Derby and Derbyshire

    AI-generated summary

    Miriam STONE · 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

    Miriam Stone died on 20 February 2022 after being found with a ligature around her neck in a mental health unit on 18 February, following admission after an overdose. The concerns included uncertainty over responsibility for admission tasks during staff handover, a lack of formal policy protecting handover time, inadequate or incomplete risk and safety assessments, and observations that were not individually assessed and were found likely inappropriate.

    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 clearly allocate responsibility for admission tasks during staff handover

    Wider context from the report

    “Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required. The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy. The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different organisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact. The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur. ”

    Source location

    Miriam STONE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Derby and Derbyshire

    AI-generated summary

    Alice Jean FOX · 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

    Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.

    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 complete core admission assessments after late-night arrival at the rehabilitation hospital

    Wider context from the report

    “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate. ”

    Source location

    Alice Jean FOX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. South Wales Central

    AI-generated summary

    Manon Edie Jones · 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

    Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.

    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

    Impaired ability of admission clinicians to assess patients

    Wider context from the report

    “(3) The absence of a single in and outpatient clinical record impaired the ability of the clinicians at the unit on admission to be able to assess Manon, fix a safe levels of observations, and safeguard her. ”

    Source location

    Manon Edie Jones · Prevention of Future Deaths report
    Page 2 · 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

    Unavailability of community care records to clinicians on admission

    Wider context from the report

    “(1) The clinicians assessing Manon on admission to Ty Llidiard did not have available to them the records of her care made in the community by the Crisis team, the Community Intensive Treatment team or the University Hospital of Wales ”

    Source location

    Manon Edie Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 medical clerking after admission

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. East London

    AI-generated summary

    David Ayontunde Walker · 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

    David Ayontunde Walker died on 27 November 2020 after his mental health deteriorated following discharge from hospital. The report identified concerns about repeated changes of care co-ordinator and the failure to obtain and share important risk information between the mental health trusts, resulting in an incomplete discharge risk assessment.

    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 obtain collateral healthcare information from other trusts on hospital admission

    Wider context from the report

    “2. On admission to hospital on the 10th November 2020 no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought. ”

    Source location

    David Ayontunde Walker · 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

    Communicate to inpatient staff how to access external shared-link records for collateral information.

    Verbatim wording from the response

    “No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.”

    Source location

    Response from North East London NHS Foundation Trust
    Page 2 · response
    Published 22 October 2021

    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

    Amend the electronic admission checklist to prompt staff to identify other Trust involvement and obtain collateral information.

    Verbatim wording from the response

    “No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.”

    Source location

    Response from North East London NHS Foundation Trust
    Page 2 · response
    Published 22 October 2021

    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

    Send a further reminder to medical and nursing staff to obtain collateral information at the earliest opportunity.

    Verbatim wording from the response

    “No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.”

    Source location

    Response from North East London NHS Foundation Trust
    Page 2 · response
    Published 22 October 2021

    Open published response

  9. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Harold Blackshaw · 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

    Harold Blackshaw died from COVID-19 on 1 March 2021 after falls, a fractured neck of femur, hip dislocations, surgery and subsequent admissions to hospital and care homes. The report raised concern that Grange Ward lacked an admission process to assess patients’ individual needs and put appropriate falls-prevention measures in place.

    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 assess patients' needs and required measures during the admission process

    Wider context from the report

    “During the course of the inquest evidence was given regarding the admission process for patients admitted to the Haywood Hospital. Specifically the rehabilitation ward which Mr Blackshaw was admitted to (“Grange Ward”). It was heard that this ward was primarily for the rehabilitation of elderly patients that were recovering from injuries; some after falls. Some patients were high risk of falls. The evidence given suggested that there was no admission process which assessed the needs of each patient and what measures should be put in place to meet their needs, before they came to the ward, or when they were on the ward. This gives me concern that a future death could result. ”

    Source location

    Harold Blackshaw · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Mid Kent and Medway

    AI-generated summary

    Catherine Jux · 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

    Catherine Jux died aged 86 on 5 April 2021 while being transported to hospital by ambulance after choking on food at Elvy Court Nursing Home. The substantive concerns were that a risk assessment was not completed within 24 hours of admission, staff did not identify this omission, and the home lacked an adequate auditing process for completed assessments.

    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 complete risk assessments within 24 hours of admission

    Wider context from the report

    “Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that: (1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home. (2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this. (3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission. ”

    Source location

    Catherine Jux · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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