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. County Durham and Darlington

    AI-generated summary

    David Peter Greenfield · 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 Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful 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

    Lack of drug screening for patients admitted to alcohol detoxification programmes

    Wider context from the report

    “2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs. The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are in a patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future. ”

    Source location

    David Peter Greenfield · Prevention of Future Deaths report
    Page 1 · 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

    Provide detoxification hospitals with urine drug-screening kits and instruct staff to test patients where illicit-drug use is indicated.

    Verbatim wording from the response

    “We are in agreement with you that we should routinely use urine drug screens across all of our detoxification services as part of the assessment process and where necessary on an on-going basis thereafter. Since the request we have reviewed this practice and learnt that a number of hospitals are routinely undertaking urine drug screens on those patients who are admitted for alcohol detoxification. Our intention is to ensure that our hospitals all have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs prior to or at the point of admission. Our intention is to ensure that these kits are readily available at relevant hospital sites by the end of February 2014.”

    Source location

    2014-0518-Response-by-Priory-Group
    Page 2 · response
    Published 27 November 2014

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Maureen Annette ELLETT · 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

    The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

    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 protocol and assigned responsibility for admission bloods

    Wider context from the report

    “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet. Acopia was recorded as the main diagnosis. None of the early A & E paperwork was completed. The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed. No Admission bloods were taken and in this respect there is no protocol or guidance concerning: a) that bloods should be taken when patients are admitted to A & E by Ambulance or b) who should take these bloods. ”

    Source location

    Maureen Annette ELLETT · Prevention of Future Deaths report
    Page 1 · 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

    Amend the doctors’ induction programme to emphasize doctors’ responsibility for ensuring appropriate blood tests are taken and ordered.

    Verbatim wording from the response

    “We do not believe it is appropriate for any decision about whether or not blood is to be taken to be based on the mode of transport by which they arrive (ambulance, own transport etc). We agree that Mrs Ellett’s blood should have been taken for testing, and confirm that while blood may be taken by medical or nursing staff, it is the responsibility of the doctor to ensure that appropriate blood tests have been taken and appropriate blood tests ordered. The doctors’ induction programme has”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 31 October 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Blood-testing decisions should not be based on the patient’s mode of transport.

    Verbatim wording from the response

    “We do not believe it is appropriate for any decision about whether or not blood is to be taken to be based on the mode of transport by which they arrive (ambulance, own transport etc). We agree that Mrs Ellett’s blood should have been taken for testing, and confirm that while blood may be taken by medical or nursing staff, it is the responsibility of the doctor to ensure that appropriate blood tests have been taken and appropriate blood tests ordered. The doctors’ induction programme has”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 31 October 2014

    Open published response

  3. Black Country

    AI-generated summary

    Mr John Dodd · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

    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 first assessment by medically qualified staff in A&E

    Wider context from the report

    “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

    Source location

    Mr John Dodd · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester West

    AI-generated summary

    Margaret 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

    Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

    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 obtaining patients’ previous diabetes medication regimes

    Wider context from the report

    “(1) Following Mrs Walker’s admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012. When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed. ”

    Source location

    Margaret 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

    Issue further guidance clarifying medicines reconciliation responsibilities.

    Verbatim wording from the response

    “The Trust recognises the vital importance of the recording and sharing of accurate information with regard to medication. This is covered within our core training programme on our medicines policy. As a result of this case we have reviewed our policy and processes and will be issuing further guidance to raise awareness of the medicines reconciliation process and particularly the specific responsibilities of staff with regard to this.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    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 Medicines Management Team access to electronic Summary Care Records.

    Verbatim wording from the response

    “Your letter states that Mrs Walker was admitted on 4 March 2012; however I would like to confirm that Mrs Walker was admitted as a detained patient on 4 August 2012. I note your concerns with the apparent delay in obtaining an accurate medication regime. 6 August 2012 was a Monday and while it was a significant delay (up to 48-hours after admission), it was the earliest possibility at that time for obtaining GP practice held information needed to complement other information sources to establish an accurate medication regime. Recently members of the Medicines Management Team have gained access to the electronic Summary Care Record for patients; this links to GP practices and provides access to the”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    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

    Include routine Summary Care Record access in the new clinical IT system work plan.

    Verbatim wording from the response

    “Routine access to the Summary Care Record is included in the work plan for the Trust’s new Clinical IT system (RiO). Specifically this will improve medicines reconciliation out of routine working hours.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 25 March 2014

    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 regular auditing and reporting of medicines reconciliation failures.

    Verbatim wording from the response

    “The Medicines Management Team provide services on our in-patient wards daily (Monday-Friday) to support a number of functions including medicines reconciliation. The team’s work is audited regularly and the accuracy of their work is assured. The Trust has developed and put in place a process to regularly audit and to report any failings in the medicines reconciliation process.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 25 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The admission date was 4 August 2012, and obtaining GP medication information on 6 August was the earliest possibility at that time.

    Verbatim wording from the response

    “Your letter states that Mrs Walker was admitted on 4 March 2012; however I would like to confirm that Mrs Walker was admitted as a detained patient on 4 August 2012. I note your concerns with the apparent delay in obtaining an accurate medication regime. 6 August 2012 was a Monday and while it was a significant delay (up to 48-hours after admission), it was the earliest possibility at that time for obtaining GP practice held information needed to complement other information sources to establish an accurate medication regime. Recently members of the Medicines Management Team have gained access to the electronic Summary Care Record for patients; this links to GP practices and provides access to the”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 25 March 2014

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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 initial nursing and medical assessment in A & E

    Wider context from the report

    “(1) Delay in being seen both by Nursing Staff and Doctors in A & E. Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013. Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. South Yorkshire (Western)

    AI-generated summary

    Mrs May Gibson · 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

    Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

    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 and reconcile pre-admission and admission assessments

    Wider context from the report

    “2) the failure to make a proper pre-assessment, or query the differences in assessment with the City Council, or to make a further assessment upon admission; ”

    Source location

    Mrs May Gibson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. West Sussex

    AI-generated summary

    Phillip Arthur Pratt · 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

    Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

    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 medication reconciliation on admission and pre-assessment

    Wider context from the report

    “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken. (1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication; (2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed; (3) The onset of agitation and confusion had been recognized, with a (4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication; (5) There was a delay in x-raying the shoulder. The report comments (6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available. ”

    Source location

    Phillip Arthur Pratt · Prevention of Future Deaths report
    Page 3 · 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