Recurring concern

Unreliable welfare-call arrangements when patients cannot receive calls

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First reported 3 Sep 2015•Latest report 12 Oct 2015

Definition

What this concern includes

Includes failures in dedicated welfare-call and callback arrangements for patients or people requiring a response when direct communication is unavailable or unsuccessful, including policy, identification of an appropriate lifeline or third party, call initiation, timing, repeated attempts, recording and escalation where these support timely welfare assessment.

Not included

  • Excludes ordinary appointment, referral or routine follow-up communication failures where no welfare-call or callback-for-safety process is identified.
  • Excludes failures occurring after reliable welfare contact has been established, including the quality of subsequent clinical assessment or treatment.
  • Excludes generic telephone, staffing or communication deficiencies unless they directly impair welfare calls or callbacks made because direct patient contact is unavailable.
  • Excludes missing-person or general failed-contact responses where no dedicated welfare-call, lifeline or third-party callback arrangement is supported.
  • Excludes emergency ambulance dispatch and response failures after an appropriate welfare escalation or emergency call has been initiated.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2015–2015

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1
East Midlands Ambulance Service NHS Trust1
Kettering General Hospital NHS Foundation Trust1
Sister of Kala Skinner1
South Western Ambulance Service 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.

  1. Northamptonshire

    AI-generated summary

    Mrs Withers · 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 Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at 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

    Inadequate policy for calling back a lifeline or third party when the patient cannot receive calls

    Wider context from the report

    “2) The policy in relation to calling back a life line/third party where the patient is unable to receive calls. ”

    Source location

    Mrs Withers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Avon

    AI-generated summary

    Ms. Kala Michelle Skinner · 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

    On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

    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 make sufficient and timely welfare calls when no response is provided

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”

    Source location

    Ms. Kala Michelle Skinner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026