Recurring concern

Unreliable dissemination of safety-critical clinical guidance and learning

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First reported 19 Sep 2013•Latest report 4 Nov 2025

Definition

What this concern includes

Includes failures to disseminate, cascade, communicate or make accessible safety-critical clinical guidance, policy or practice changes, revised training, best practice and lessons learned to the clinicians, teams or care units responsible for applying them, including the anchor's clinical-care policy and practice changes and comparable cross-unit or cross-clinician dissemination failures.

Not included

  • Excludes failures in the substantive content, evidence base or updating of clinical guidance where dissemination is not the unsafe condition.
  • Excludes failures to implement or embed a change after it was reliably disseminated, unless the report also identifies a dissemination failure.
  • Excludes generic communication, record-keeping, training or organisational-learning deficiencies without a material safety-critical clinical guidance, policy-change, best-practice or learning dissemination context.
  • Excludes dissemination processes bounded to a distinct named system, hazard or statutory pathway when that named concern provides the more specific supported boundary.
Reports
14

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
16

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
National Institute for Health and Care Excellence3
NHS England2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
General Medical Council1
George Eliot Hospital NHS Trust1
Healthcare Safety Investigation Branch1
Health Centre1
North West Ambulance Service NHS Trust1
Public Health England1
Southampton General Hospital1
South West Midlands Newborn Network SENAT1
Stepping Hill Hospital1
St George's Hospital1

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. Portsmouth and South East Hampshire

    AI-generated summary

    Scott Douglas Hooper · 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

    Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.

    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 disseminate and implement weight-estimation learning and training for clinical staff treating high-risk patients

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”

    Source location

    Scott Douglas Hooper · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Wilfrid Pearson · 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

    Wilfrid Pearson was admitted to Tameside Hospital on 22 April 2015 with epilepsy, developed status epilepticus, and died at a local hospice about a month later. Concerns included possible failures in updating and communicating the status epilepticus protocol, unclear and incomplete records, inadequate escalation of care, staffing pressures, and the legal basis for detaining him after he left the ward.

    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 promulgate the Status Epilepticus protocol to all relevant medical staff

    Wider context from the report

    “1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated and whether and how it was promulgated to all relevant medical staff including locum doctors. ”

    Source location

    Wilfrid Pearson · 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

    Disseminate the Status Epilepticus Policy through junior doctor training, medical team discussions and the Trust intranet.

    Verbatim wording from the response

    “As well as making improvements to the Trust’s local policy, steps have been taken to ensure all clinicians at the Trust have awareness of the policy. It has been included as part of the training of Junior Doctors, and has been discussed with the Trust’s medical teams. The policy is also easily available for clinicians on the Trust’s intranet.”

    Source location

    W-Pearson-Response
    Page 1 · response
    Published 24 February 2016

    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 the Status Epilepticus Policy in the mandatory Junior Doctor Grand Round.

    Verbatim wording from the response

    “The Trust’s Education Department have confirmed that Status Epilepticus Policy will now be included as part of the Junior Doctor Grand Round (this is the training programme that all Junior Doctors must complete). The Trust’s intranet has a search facility for documents which directs staff seeking guidance to documents including the Status Epilepticus Standards. The search also directs staff to the NICE Guidance Quality Standards for Epilepsies.”

    Source location

    W-Pearson-Response
    Page 2 · response
    Published 24 February 2016

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Doreen Wood · 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

    Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

    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 ensure learning from INR dosing events reaches all GPs at the practice

    Wider context from the report

    “(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”

    Source location

    Doreen Wood · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Birmingham and Solihull

    AI-generated summary

    Caitlynn Bethany Jane Bennet and 2 others · 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 deaths of Caitlynn Bethany Jane Bennet, Mohammed Gulam Mohinudeen and Alfie-Scott Harris. It raises concerns about cardiac tamponade as a complication of central lines used for parenteral nutrition, including whether neonatal staff recognise the risk and whether best practice is shared between units. In Alfie-Scott Harris’s case, the report identified failures in the placement of the long-line end, although these were not considered gross.

    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 NNUs to share best practice for limiting cardiac tamponade risk

    Wider context from the report

    “(1) NNU staff are not aware that cardiac tamponade may not be such a rare complication of TPN feeding as is thought. (2) NNUs may not be sharing best practice to limit this complication. This is the second Report that I am sending out in relation to an issue about babies dying of cardiac tamponade as a complication of central lines being put in for parenteral nutrition. I have now heard the evidence in relation to the third death and I am sufficiently concerned to write a further report. For everybody’s information, the first report was sent to Sir David Nicholson, Chief Executive of the National Health Service and it must have been forwarded onto The Royal College of Obstetricians and Gynaecologists by The National Health Services. The response from the Royal College stated that this was not a matter for them but it is a matter for the Royal College of Paediatrics and Child Health. In the meantime, matters have overtaken that and I have heard the Inquest in relation to the third death. I had asked for a report from a Senior Consultant Neonatologist, ████████ who has written me a report indicating essentially, that she has no concern about links between the three cases and that it is a known complication. I am aware that this doctor has now retired. In the third case that I heard of Alfie-Scott Harris, I have found that there were failures in relation to the placement of the end of the long line that he had in, although I did not find these to be gross, and, despite ████████ report, at the very least, it seems to me, that it should not be assumed that this is a rare complication. I have heard that City Hospital have brought in new measures to reduce the incidence of any failures in the future, (for instance having a high resolution x-ray scanning equipment on the Neonatal Unit as well as in Radiology, so that the clinicians can look at the x-rays. I refer to my summing up which is attached to this document). I am concerned that each Unit may not be sharing best practice about what is being done to minimise any risk. I am very conscious that this is a complicated medical issue which I have heard in some detail but you, as a clinician, will no doubt be aware of significant medical research that assists with clinical decision making about care of these lines. However, from my point of view, the first Inquest I heard in relation to this type of death was one where I was told that this was a complication which was incredibly rare. I am also told in the last Inquest of Alfie-Scott Harris, that there have lessons that have been learned and that changes have been made. I am not assured that any changes that have been made in one unit, had not been at least considered in another unit in relation to the same facts. ”

    Source location

    Caitlynn Bethany Jane Bennet and 2 others · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026