Recurring concern

Failure to reliably telephone patients when follow-up or assessment requires it

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First reported 24 Mar 2014•Latest report 12 Aug 2024

Definition

What this concern includes

Includes failures to make required telephone contact with patients or their families for patient follow-up, requested contact, or assessment of a requested service.

Not included

  • Excludes failures to telephone treating healthcare professionals about abnormal results, unless the concern is specifically patient or family telephone follow-up or assessment.
  • Excludes general failures of referral escalation, investigation tracking, or safety-netting that do not specifically involve required telephone contact.
  • Excludes isolated communication failures unrelated to a required patient or family telephone contact.
Reports
18

Distinct published reports

Individual concerns
18

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
23

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.

Department of Health and Social Care3
Welsh Ambulance Services NHS Trust3
South East Coast Ambulance Service NHS Foundation Trust2
Welsh Government2
Aneurin Bevan University LHB1
Cardiff & Vale University LHB1
Central and North West London NHS Foundation Trust1
Daughter of the deceased1
Frimley Health NHS Foundation Trust1
Healthcare Inspectorate Wales1
Hereford Medical Group1
Kent and Medway Mental Health NHS Trust1
King's College Hospital1
London Ambulance Service NHS Trust1
NHS England1

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. Sunderland

    AI-generated summary

    Raymond Henry Davidson (Raymond) · 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

    Raymond Henry Davidson died at home on 10 June 2017 after ambulance responses to urgent and emergency calls did not attend before he stopped breathing. The report identified ongoing ambulance resource shortages and delays in responding to urgent cases, as well as concerns that the initial clinical review was not sufficiently robust because telephone contact was not made directly with Raymond.

    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 direct telephone contact with the patient during initial clinical review

    Wider context from the report

    “I heard evidence that: - • the recruitment/retention of staff had improved; and • welfare calls triggered earlier clinician involvement than previously; and • although there were several other initiatives under way, operational shortages were ongoing. Raymond’s death highlighted resource issues. There was only so much NEAS could do when they simply did not have enough ambulances to send. At times demand was greater than the resources NEAS had available. The effect of urgent cases being interposed put back those cases appearing to be less urgent. In this case: - • 10 hours 51 minutes elapsed from the original 111 call; • 8 hours and 29 minutes after the urgent categorisation; and • 1 hour 3 minutes after the case was prioritised as a G2 response. This is the third such report about the same issue that I have written in recent months as I consider that there is a risk of future deaths. An urgent review of resources and their application is needed. Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly, which may have impacted on the less than robust initial clinical review of Raymond’s condition. ”

    Source location

    Raymond Henry Davidson (Raymond) · 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

    Implement the updated Urgent Ringback Procedure, prioritising direct conversation with patients wherever possible, and communicate it to relevant staff.

    Verbatim wording from the response

    “I can confirm that the updated ‘Urgent Ringback Procedure’ was approved and implemented in February 2018. The updated procedure is available and communicated onto all Call Handlers, Clinicians and Team Leaders within the Trusts Emergency Operations Centre. The new procedure puts the emphasis on direct conversation with the patient wherever possible. In relation to the 111 Clinician, the individual was provided one-to-one feedback on this case and undertook a coaching session.”

    Source location

    2018-0059-North-East-Ambulance-Service-NHS-Trust
    Page 5 · response
    Published 8 June 2018

    Open published response
  2. West Sussex

    AI-generated summary

    Barbara Joan Howard · 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

    Barbara Joan Howard fell at home on 19 July 2017, experienced delays in ambulance response and backup, and was taken to hospital, where she died from injuries sustained in the fall on 20 July 2017. The concerns included ambulance and clinician staffing shortages, failure to make a priority-assessment call when the response exceeded the target time, and ambulance-call auditing below the stated target.

    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 contact patients to ascertain call priority when response targets are missed

    Wider context from the report

    “(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category. On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short. ”

    Source location

    Barbara Joan Howard · 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

    Recruit and train Support Call Takers to conduct welfare callbacks and escalate clinically concerning cases.

    Verbatim wording from the response

    “a. The creation of a new role – “Support Call Taker”. This is a non-clinical role designed to alleviate the pressure on EOC clinicians. The Support Call Takers will work in the EOC carrying out welfare callbacks. This means that where we are not able to dispatch an ambulance resource within the target time, the SCT will call the patient or the caller to ensure that the patient has not got any worse and to offer advice on such matters as keeping warm, staying hydrated and taking prescribed medication. The SCT will have the power to escalate to a clinician any patient about whom there are clinical concerns. We are recruiting and training for this role now.”

    Source location

    2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 27 February 2018

    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

    Introduce the Surge Management Plan with time parameters and escalation controls for demand exceeding available resources.

    Verbatim wording from the response

    “c. A change to the way we deal with situations where actual demand for our resources on any shift exceeds forecast demand and therefore exceeds available resources. For a number of years, we have had in place a Demand Management Plan to cope with this situation. This is no longer appropriate, since the introduction of the Ambulance Response Programme (“ARP”). ARP is a national program instigated by NHS England to address the inappropriate categorisation of 999 ambulance calls and dispatch of resources to them. ARP has introduced a new set of nationally prescribed categorisations and response times. I attach a chart summarising the new system. The objective is to match the resource requirements. Secamb introduced ARP on 22 November 2017.”

    Source location

    2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 27 February 2018

    Open published response
  3. Inner South London

    AI-generated summary

    Jamie Pashley · 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

    Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    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 telephone contact between discharge and first appointment review

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · 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

    Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.

    Verbatim wording from the response

    “The Trust’s view is that a more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient’s GP may be a more effective approach. There is currently a trial underway in which King’s College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    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

    Expanding telephone follow-up would require additional funding for the Trust’s alcohol dependency service.

    Verbatim wording from the response

    “As is the case with the provision of fixed appointments, the Trust recognises that making telephone contact in this interim period may be beneficial for some alcohol dependency patients. However, it is again unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    Open published response
  4. Inner North London

    AI-generated summary

    Emily VOUKELATOU · 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

    Emily Voukelatou left North Camden Crisis House after writing notes of intent, travelled to Beachy Head on 30 June 2016, and jumped from the cliff. Concerns included the lack of routine involvement of family members in care and Crisis House’s failure to return her sister’s repeated calls before and after her 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

    Failure to route and return relatives’ calls

    Wider context from the report

    “2. Ms Voukelatou’s sister telephoned Crisis House several times, very worried, both before and after Ms Voukelatou’s death (not having been informed that her twin had died), but her calls were never returned. Apparently, these were not passed on to the right people, but witnesses in court were not aware of the detail of this. Leaving relatives’ repeated calls unanswered cannot be right. It loses potentially valuable information, creates additional anxiety and is simply discourteous. ”

    Source location

    Emily VOUKELATOU · 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 North Camden Crisis House staff guidance to provide families with clear contact details and direct access to a senior staff member.

    Verbatim wording from the response

    “In light of the information set out above we have unfortunately been unable to get to the bottom of what happened when ████████ tried to contact the Crisis House, and why her calls were not connected. From our enquiries with the switchboard supervisor, and ████████ however, we are satisfied that switchboard staff have the correct number for the crisis house. Nevertheless, given the significance of this issue, we have issued staff at North Camden Crisis House with clear guidance to ensure that numbers and contact details are clearly provided to families participating in a service user’s care so they are able to speak directly to a senior staff member.”

    Source location

    2017-0004-Response-by-Camden-and-Islington-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    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

    Existing switchboard arrangements are considered sufficient because staff have the correct Crisis House number and can transfer calls or provide direct contact details.

    Verbatim wording from the response

    “████████, Head of Facilities, has confirmed that switchboard staff have the number for all crisis houses, including North Camden Crisis House, and that staff would transfer an individual’s call to the crisis house, and also give them the direct”

    Source location

    2017-0004-Response-by-Camden-and-Islington-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    Open published response
  5. South Wales Central

    AI-generated summary

    Ronald Hamer · 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

    Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.

    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 timely follow-up calls to update, advise and reassess emergency callers

    Wider context from the report

    “2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call. A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made. ”

    Source location

    Ronald Hamer · 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

    Develop an action plan addressing the Regulation 28 improvement requirements.

    Verbatim wording from the response

    “I am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased). I would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the key actions for improvement. Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”

    Source location

    2016-0149-Response-by-Welsh-Ambulance-Services-NHS-Trust
    Page 1 · response
    Published 20 April 2016

    Open published response
  6. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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 provide timely and regular follow-up contact

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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 and implement AABIT standard operating procedures.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response
  7. Manchester West

    AI-generated summary

    Margaret Elaine Wright · 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 Elaine Wright developed hepatitis C, liver cirrhosis and hepatocellular carcinoma following contaminated blood transfusions, and died in hospital on 23 December 2014 after her condition deteriorated following surgery. The principal concern was that the doctors’ practice did not telephone the patient or her family to obtain further information when a home visit was requested, and the doctor was unaware of her recent surgery because the practice had not received a discharge summary, resulting in a delayed visit.

    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 telephone patients or their families for further information when a home visit is requested

    Wider context from the report

    “(1) The Doctors did not at that time telephone patients or their families when a home visit had been requested to obtain further information about the patient’s situation. Had that happened in this case Mrs Wright would have received a priority visit, although there was no evidence that this would have affected the outcome. Evidence was given that since Mrs Wright’s death a system of a Doctor telephoning patients or their families prior to visiting had been introduced, both in the Doctors practice in question and in the local area. Evidence was given that this best practice should be drawn to the attention of the Secretary of State for Health in order to prevent future deaths. ”

    Source location

    Margaret Elaine Wright · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Surrey

    AI-generated summary

    Phyllis Barnes · 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

    Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.

    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

    Unreliable promised telephone follow-up

    Wider context from the report

    “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised ”

    Source location

    Phyllis Barnes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026