Recurring concern

Failure to incorporate relevant collateral and professional views into clinical assessment

First to latest report 13 Jan 2014 — 6 Feb 2026

Reports that mention this concern
17
Times this concern has been raised
17
Stated actions linked to this concern
33

What this concern includes

Includes failures to obtain, communicate, reconcile or consider relevant collateral or professional views as part of a clinical assessment or consequential clinical evaluation, including views from parents, nursing staff and treating doctors about the patient's presentation, condition or fitness.

What is not included
  • Excludes generic communication or workplace-culture deficiencies where relevant views are not material to a clinical assessment.
  • Excludes failures to act after relevant views were obtained and considered, unless the assessment process itself was also deficient.
  • Excludes routine family involvement, multidisciplinary coordination or specialist consultation where the asserted unsafe condition is not failure to incorporate relevant views into the clinical assessment.
  • Excludes assessment failures involving only missing records, inadequate examination or unsuitable assessment location when no failure to consider relevant collateral or professional views is identified.

Reports and published responses 17 reports

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

  1. Manchester West

    AI-generated summary

    Karl Qolf Jamil Englemak Cassimjee · 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

    Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

    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 operational procedures to ensure nurses' concerns are taken into account in specialist evaluation and detention decisions

    Wider context from the report

    “1. Brief circumstances of matter of concern a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital); b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner; c. The assessment, as recorded by the Registrar was accepted to be sub-optimal; d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team. e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim). f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account. ”

    Source location

    Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Patricia Forshaw · 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

    Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.

    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 relevant preliminary examination information to Doctors

    Wider context from the report

    “ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20th October 2016 and the advice to give paracetamol was not recorded in any Hospital records. Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased. The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor. ████████ commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw. ”

    Source location

    Patricia Forshaw · 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

    Reinforce nurses’ recording of relevant care and notification of reviewing clinicians, including through local nursing induction.

    Verbatim wording from the response

    “All of our nurses are aware of their duty to ensure patient records are accurate and to document relevant information as appropriate. However I understand that a notification has been circulated to all nursing staff by the Matron for Unscheduled Care to reiterate the requirement for nurses to document in the patient’s notes any relevant care or treatment provided. The Clinical Director for Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at the Clinical Governance Meeting. I have also been informed that this notification will be incorporated into the ongoing local induction for nursing staff.”

    Source location

    2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 3 · response
    Published 2 November 2017

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 family information into falls risk assessment

    Wider context from the report

    “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 and properly consider relevant information from parents

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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

    Review the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.

    Verbatim wording from the response

    “With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response

  5. Inner North London

    AI-generated summary

    Finnulla Catherine MARTIN · 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

    Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left 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 obtain collateral history from family members before concluding the interview

    Wider context from the report

    “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin. ”

    Source location

    Finnulla Catherine MARTIN · 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

    Pilot the mental health assessment proforma and make it available to mental health colleagues.

    Verbatim wording from the response

    “b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 2 · response
    Published 29 April 2015

    Open published response

  6. Cornwall

    AI-generated summary

    JULIA SHEEREN DELL · 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

    Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

    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 reconcile reassurance about mood stabilisation with recent concerns about wellbeing

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”

    Source location

    JULIA SHEEREN DELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Michael Brendan O’SULLIVAN · 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

    Michael O’Sullivan took his own life by hanging while suffering anxiety and depression, following a recent assessment by a DWP doctor that he was fit for work. The assessing doctor and the ultimate decision maker did not obtain or consider reports from his treating doctors, including his general practitioner, psychiatrist and clinical psychologist.

    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 assessing doctors to take into account treating doctors’ views

    Wider context from the report

    “The DWP assessing doctor (who saw Mr O’Sullivan for a 90 minute consultation) did not take into account the views of any of Mr O’Sullivan’s treating doctors, saying that the ultimate decision maker would do that. However, the ultimate decision maker (who is not, I understand, medically qualified) did not request and so did not see any reports or letters from Mr O’Sullivan’s general practitioner (who had assessed him as being unfit for work), his psychiatrist or his clinical psychologist. ”

    Source location

    Michael Brendan O’SULLIVAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 existing division between Atos-trained healthcare professionals and GPs is retained because each has a distinct role and GPs generally lack relevant assessment expertise.

    Verbatim wording from the response

    “70. This issue of further medical evidence has also been considered as part of the independent review process. The distinction drawn between the respective functions of HCPs and GPs is a key element of the policy intent behind the WCA, and is supported by the British Medical Association. In its response to Professor Harrington’s call for evidence for his third independent review, the BMA said:”

    Source location

    2014-0012-Response-by-DWP
    Page 14 · response
    Published 13 January 2014

    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