Recurring concern

Incomplete clinical history-taking

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First reported 31 Mar 2014•Latest report 31 Oct 2025

Definition

What this concern includes

Includes failures to obtain a sufficiently complete and relevant patient history during clinical assessment, consultation, admission, clerking or health checks, including failure to elicit relevant information from the patient or appropriate informants.

Not included

Excludes failures limited to recording or documenting information that was already obtained, unless the report also identifies incomplete history-taking.
Excludes failures limited to communicating or handing over an already established history, unless the underlying history was not adequately obtained.
Excludes deficiencies in treatment, referral, escalation or testing where incomplete history-taking is not itself the recurring unsafe condition.

Reports: 55
Individual concerns: 58
Date range: 2014–2025
Stated actions: 96

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England11

Department of Health and Social Care6

North East London NHS Foundation Trust4

Barts Health NHS Trust3

Care Quality Commission3

Hampshire and Isle of Wight Healthcare NHS Foundation Trust3

Manchester University NHS Foundation Trust3

General Medical Council2

Greater Manchester Mental Health NHS Foundation Trust2

Medway NHS Foundation Trust2

Ministry of Justice2

North London NHS Foundation Trust2

Royal College of Emergency Medicine2

Royal College of Paediatrics and Child Health2

Surrey and Borders Partnership NHS Foundation Trust2

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.

31 Oct2025
Liverpool and the Wirral
Concerns raised1
1. Failure to obtain and consider relevant previous medical history
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure clinicians assess whether available clinical information is sufficient without delaying appropriate patient assessment.
  Stated by Marine Lake Medical PracticeStated in progress
AI-generated summary

Gloria SIMON · 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

Gloria Simon moved into a care home for respite on 9 September 2025 and died there from natural causes on 20 September after her condition deteriorated. Concerns included missed opportunities to obtain timely clinical input, the GP’s failure to undertake a face-to-face assessment after misreading oxygen saturation results, and insufficient attention to her medical history and care-home setting.

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 consider relevant previous medical history
Wider context from the report
“2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’. The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him. There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting). The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur. ”
Source location
Gloria SIMON · 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
Ensure clinicians assess whether available clinical information is sufficient without delaying appropriate patient assessment.

Verbatim wording from the response
“It is noted on the request for care form that several of the parameters were missing. We will reiterate the importance of a full set of observation from staff to care homes, but accept that this may lie outside of the competence of some care home staff. We expect all Marine Lake clinicians to ensure they are comfortable with the clinical information available but not at the detriment of delaying appropriate assessment of the patient.”

Source location
Response from Marine Lake Medical Practice
Page 2 · response
Published 5 November 2025
Open published response
13 Oct2025
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Failure to demonstrate professional curiosity and obtain relevant information from family members
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Work with involved teams to improve professional curiosity when caring for patients.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
AI-generated summary

Abigail Eleanor Ann Jelly · 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

Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and 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
Failure to demonstrate professional curiosity and obtain relevant information from family members
Wider context from the report
“Abigail was known to the community mental health services for just a few weeks. She had been living with her parents immediately before she died and they had attended medical appointments with her. Abigail’s parents were not spoken to by mental health professionals about their daughter’s circumstances when they would have been able to provide valuable information about her research into and planning around ending her life. It was accepted that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally and I am concerned that there is a risk of future deaths. ”
Source location
Abigail Eleanor Ann Jelly · 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
Work with involved teams to improve professional curiosity when caring for patients.

Verbatim wording from the response
“There was also a lack of professional curiosity in working with Abigail, and this has been worked on with the teams involved.”

Source location
Response from Hampshire and Isle of Wight Healthcare
Page 1 · response
Published 14 October 2025
Open published response
10 Aug2025
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to include available family members in clerking patients with dementia
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Require LML staff to involve relatives and carers throughout assessment and care, documenting and justifying any proportionate exclusion.
  Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completed
2. Action
  Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
  Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completed
3. Action
  Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
  Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completed
AI-generated summary

Brian Ingram · 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

Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

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 include available family members in clerking patients with dementia
Wider context from the report
“2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history. ”
Source location
Brian Ingram · 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
Require LML staff to involve relatives and carers throughout assessment and care, documenting and justifying any proportionate exclusion.

Verbatim wording from the response
“2.2 It was suggested in evidence at the inquest, that the practice of asking a family member to remain in the ambulance, may have been a remnant of procedure adopted during the COVID-19 pandemic. LML has reflected upon the decision of the ECA ambulance crew in this case, which was not in line with their policy. Following the inquest, LML has:”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 2 · response
Published 14 October 2025
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
Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.

Verbatim wording from the response
“2.3 Whilst CFT was not aware that Mr Ingram’s daughter was waiting in the ambulance in this case, we appreciate that had our Minor Injuries Unit (MIU) staff come to the ambulance to carry out an initial assessment of Mr Ingram and consider his suitability for review and/or treatment in the MIU, they would have discovered her waiting there, and had the opportunity to take any relevant history. It is established MIU practice to assess patients in the ambulance, prior to checking them in. This is expressly stated in the MIU Operational Policy, which sets out the procedure for patients being brought into the MIU by ambulance, as follows:”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 3 · response
Published 14 October 2025
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
Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.

Verbatim wording from the response
“2.5 The facts relating to Mr Ingram’s inquest have also been used as a case study and presented at the Learning from Experience (LFE) Forum, a meeting attended by all MIU clinical leads, to discuss any collective issues to be addressed, and to share learning and best practice across CFT. It was reiterated at the LFE Forum, that in accordance with policy, all patient arrivals via ambulance should be initially assessed in the ambulance, and a full assessment of the patient should be carried out by an MIU clinician (discussed further below).”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 4 · response
Published 14 October 2025
Open published response
9 Jul2025
West Sussex, Brighton and Hove
Concerns raised1
1. Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Add family-history prompts, including venous thromboembolism, to the pre-operative assessment form.
  Stated by Surrey and Sussex Healthcare NHS TrustStated completed
2. Action
  Add the family-history question to the patient questionnaire through a future questionnaire-service update.
  Stated by Surrey and Sussex Healthcare NHS TrustStated planned
3. Action
  Undertake an after-action review to identify how the gap arose and establish learning and remedial actions.
  Stated by Surrey and Sussex Healthcare NHS TrustStated completed
AI-generated summary

Mr Marriott · 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 Marriott underwent haemorrhoidal artery ligation with mucopexy surgery as a day patient and died at home on 15 April 2024; a post-mortem found pulmonary embolism, which the evidence indicated resulted from the surgery. The pre-assessment system did not directly require questions about a patient's haematological family history or record negative answers about the patient's own haematological history.

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 the pre-day-surgery assessment system to require questions about patients' haematological family history
Wider context from the report
“The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematological history ”
Source location
Mr Marriott · 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
Add family-history prompts, including venous thromboembolism, to the pre-operative assessment form.

Verbatim wording from the response
“The patient questionnaire did not have a place for the patient to enter this important family history. The pre-operative assessment form did not have prompts for the question to be reviewed or asked. The Trust has now added an extra question on the pre-operative assessment ‘power’ form on the Family History Page. The Trust has also included other potential family history that may need further investigation (for example: cardiac, musculoskeletal).”

Source location
Response from Surrey and Sussex Healthcare NHS Trust
Page 2 · response
Published 16 July 2025
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
Add the family-history question to the patient questionnaire through a future questionnaire-service update.

Verbatim wording from the response
“The Trust has not added this question to the patient questionnaire, but this will be completed with a future update of the questionnaire service itself making the whole process easier for patients. This action will be completed by January 2026.”

Source location
Response from Surrey and Sussex Healthcare NHS Trust
Page 2 · response
Published 16 July 2025
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
Undertake an after-action review to identify how the gap arose and establish learning and remedial actions.

Verbatim wording from the response
“In addition to these urgent clinical and administrative changes, the Trust has also undertaken an After-Action Review to ascertain how this gap was not identified earlier, and to seek recommendations and actions to ensure any learning from the death of a patient is established promptly and action taken.”

Source location
Response from Surrey and Sussex Healthcare NHS Trust
Page 2 · response
Published 16 July 2025
Open published response
28 May2025
Essex
Concerns raised1
1. Failure to elicit additional risk information from patients
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Provide reflective supervision to the staff member involved in the missed communication.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Julie Sheila Beasley · 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

Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.

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 elicit additional risk information from patients
Wider context from the report
“(2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team. ”
Source location
Julie Sheila Beasley · 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
Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.

Verbatim wording from the response
“This event was led by the Director of Quality and Safety and Operational Associate Director on the 19th August 2024 with a focus on assessment and family involvement. A follow up Urgent care away day took place on 1st May 2025 to review all learning, data and incident reporting across 2023- 2024 for urgent care to ensure joined up thematic learning and review. The scrutiny of deadlines and impact continues to be reviewed at the monthly Urgent care Quality and safety meetings.”

Source location
Response from Essex Partnership University NHS Trust
Page 2 · response
Published 4 June 2025
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 reflective supervision to the staff member involved in the missed communication.

Verbatim wording from the response
“By way of further assurance, reflective supervision is being undertaken with the individual staff member who did not speak with Mrs Beasley.”

Source location
Response from Essex Partnership University NHS Trust
Page 3 · response
Published 4 June 2025
Open published response
13 May2025
Surrey
Concerns raised1
1. Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.
  Stated by Royal Surrey NHS Foundation TrustStated completed
2. Action
  Implement Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.
  Stated by Royal Surrey NHS Foundation TrustStated in progress
3. Action
  Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.
  Stated by Department of Health and Social CareStated planned
2. Action
  Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
3. Action
  Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
4. Action
  Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.
  Stated by Care Quality CommissionStated completed
5. Action
  Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.
  Stated by Royal College of Emergency MedicineStated completed
6. Action
  Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.
  Stated by Royal College of Emergency MedicineStated in progress
AI-generated summary

Rose Annie Harfleet · 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

Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.

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 routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report
“2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children. ”
Source location
Rose Annie Harfleet · 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
Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.

Verbatim wording from the response
“The Trust has a Learning Disabilities and/or Autism Policy to Support Children and Adults with Learning Disability and/or Autism. This has been developed in accordance with other national and local guidelines, including the Mental Capacity Act 2005, Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy (2021), NICE NG93 mental capacity, reasonable adjustments and quiet areas, NG11 restraint, Autism Spectrum Disorder in Adults; Diagnosis and Management – Clinical Guide CG142 (NICE 2016), NHS LD&A Programme 2025 Digital flagging and hospital passports and the Equality Act (2010). Specifically the Trust policy includes an emergency admission flow chart and information about supporting carers and engaging with them in decision making including care and interventions.”

Source location
Response from Royal Surrey County Hospital NHS Foundation Trust
Page 1 · response
Published 20 May 2025
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 Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.

Verbatim wording from the response
“The Trust is not however aware of any specific national guidance on consultation with the parents and carers of children with profound disabilities although the Trust recognises that this is an essential part of good clinical practice. Whilst not specifically related to children with profound disabilities, the Trust is aware of Martha’s Rule, and have been selected to be part of Phase 2 for implementing this. Work has commenced to address the three metrics for delivery for adults and children.”

Source location
Response from Royal Surrey County Hospital NHS Foundation Trust
Page 3 · response
Published 20 May 2025
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
Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.

Verbatim wording from the response
“To improve awareness of learning disability and autism within the health and social care system, under the Health and Care Act 2022, from 1 July 2022 Care Quality Commission (CQC) registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role. This will help to ensure that staff have the right knowledge and skills to provide safe and informed care. To support providers to meet the statutory training requirement, we have been rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce: this specifically highlights the difference that listening to parents can make.”

Source location
Response from DHSC
Page 2 · response
Published 20 May 2025
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
Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.

Verbatim wording from the response
“As part of the government’s 10-year plan and transforming the NHS from analogue to digital, the government will create a more modern NHS by bringing together a single patient record, summarising patient health information, test results, and letters in one place, through the NHS App. It will put patients and their advocates in control of their own medical history, meaning they do not have to repeat it at every appointment, and that staff have the full picture of patients’ health.”

Source location
Response from DHSC
Page 3 · response
Published 20 May 2025
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
Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.

Verbatim wording from the response
“RCPCH are actively supporting the role out of Martha’s Rule. Martha’s Rule is a patient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm.”

Source location
Response from Royal College of Paediatrics
Page 2 · response
Published 20 May 2025
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
Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.

Verbatim wording from the response
“In addition, RCPCH are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.”

Source location
Response from Royal College of Paediatrics
Page 2 · response
Published 20 May 2025
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
Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.

Verbatim wording from the response
“Speaking with and respecting patients’ families is a key aspect of the mandatory learning disability and autism training (aka the Oliver McGowan training) so all clinicians involved should be aware of this. A difficulty with regard to the implementation and regulation of providing this training has been the delay to the publication of the Code of Practice. This will give providers and CQC staff clearer guidance on the requirements of the training and for CQC to regulate. Interim guidance is available on our website.”

Source location
Response from Care Quality Commission
Page 2 · response
Published 20 May 2025
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
Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.

Verbatim wording from the response
“1. The management of children with profound disabilities within a hospital setting In September 2024, the Royal College of Emergency Medicine (RCEM) published a Learning Disabilities Toolkit [1]. This resource includes information about how best to approach the management of people with a learning disability and suggestions on how to make reasonable adjustments in an ED setting. The toolkit also makes specific mention of intra-abdominal pathology and aspiration. The RCEM also provide additional online educational resources related to Learning Disabilities [2]. The RCEM feel it would not be appropriate to comment about the care delivered in the in-patient setting.”

Source location
Response from Royal College of Emergency Medicine
Page 1 · response
Published 20 May 2025
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
Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.

Verbatim wording from the response
“2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting The RCEM Learning Disability Toolkit [1] emphasises the importance of listening to family and carers of people with a learning disability in the ED. The RCEM are represented in the group developing the ED version of the national paediatric early warning system (nPEWS) with NHS England. A key component of the nPEWS (and the current draft of the emergency department specific nPEWS score - EDnPEWS) is parental/carer concern [3]. The response from the parent/carer is built into the escalation response. The RCEM is also supportive of the work just commencing via NHS England’s Patient Safety Collaborative, which is looking to test the use of Martha’s Rule in the ED setting. We would also note”

Source location
Response from Royal College of Emergency Medicine
Page 1 · response
Published 20 May 2025
Open published response
14 May2024
Cornwall and Isles of Scilly
Concerns raised2
1. Lack of professional curiosity about drug-taking and its clinical contribution
2. Failure to share relevant presentation information with family
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Publish statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.
  Stated by Department of Health and Social CareStated completed
Respondent positions 1
1. Position
  The Integrated Care Board is expected to respond to concerns about the specific care provided.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Sally Poynton · 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

Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

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 professional curiosity about drug-taking and its clinical contribution
Wider context from the report
“a) In-patient care at Longreach Hospital Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics. ”
Source location
Sally Poynton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 share relevant presentation information with family
Wider context from the report
“a) In-patient care at Longreach Hospital Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics. ”
Source location
Sally Poynton · 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
Publish statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.

Verbatim wording from the response
“From a national perspective, we recognise how vital it is that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. On 26 January 2024, new statutory guidance for discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults was published. The guidance provides clarity in relation to how health and care systems can work together to support discharge from all mental health inpatient settings and ensure the right support is in place in the community. The guidance also includes best practice on how patients, carers and family members should be involved in discharge planning.”

Source location
2024-0267 Response from Department of Health and Social Care
Page 1 · response
Published 20 May 2024
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 Integrated Care Board is expected to respond to concerns about the specific care provided.

Verbatim wording from the response
“I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

Source location
2024-0267 Response from Department of Health and Social Care
Page 1 · response
Published 20 May 2024
Open published response
14 Mar2024
Derby and Derbyshire
Concerns raised1
1. Failure to obtain and use the timing between rupture of membranes and pre-term birth when assessing neonatal infection risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review and update guidance on Group B streptococcus, induction, labour care and pre-term labour care.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completed
2. Action
  Introduce recurring staff communications and safety briefings covering maternity and neonatal learning and risk-assessment messages.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completed
3. Action
  Launch BadgerNet to calculate rupture-to-birth intervals, flag at-risk babies and support risk-assessment audits.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated planned
1. Action
  Conduct audits of prophylactic antibiotics, holistic risk assessments and prolonged membrane-rupture identification.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated planned
AI-generated summary

Zachary Victor TAYLOR-SMITH · 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

Zachary Taylor-Smith was born preterm after an induced labour and died aged 14 hours at Royal Derby Hospital on 17 November 2022. The inquest found that he contracted an infection and that his death was contributed to by neglect, including failures relating to prophylactic antibiotics, recognition of the duration since rupture of membranes, and treatment of signs of early-onset infection. Concerns included staff understanding of infection indicators, communication between maternity and neonatal teams, systems for ensuring reviews were completed, and the safety of planned inductions given service capacity.

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 use the timing between rupture of membranes and pre-term birth when assessing neonatal infection risk
Wider context from the report
“b. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies. ”
Source location
Zachary Victor TAYLOR-SMITH · 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 update guidance on Group B streptococcus, induction, labour care and pre-term labour care.

Verbatim wording from the response
“• Guidelines review”

Source location
Response from University Hospitals of Derby and Burton
Page 4 · response
Published 21 March 2024
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 recurring staff communications and safety briefings covering maternity and neonatal learning and risk-assessment messages.

Verbatim wording from the response
“• Communication”

Source location
Response from University Hospitals of Derby and Burton
Page 4 · response
Published 21 March 2024
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
Launch BadgerNet to calculate rupture-to-birth intervals, flag at-risk babies and support risk-assessment audits.

Verbatim wording from the response
“• BadgerNet”

Source location
Response from University Hospitals of Derby and Burton
Page 5 · response
Published 21 March 2024
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
Conduct audits of prophylactic antibiotics, holistic risk assessments and prolonged membrane-rupture identification.

Verbatim wording from the response
“• Audit”

Source location
Response from University Hospitals of Derby and Burton
Page 5 · response
Published 21 March 2024
Open published response
22 Dec2023
Surrey
Concerns raised1
1. Failure to gather relevant collateral history while respecting patient confidentiality
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Barbara Ann WOODMAN · 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 Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

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 gather relevant collateral history while respecting patient confidentiality
Wider context from the report
“ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████. The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. ”
Source location
Barbara Ann WOODMAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Nov2023
East Sussex
Concerns raised1
1. Failure to seek and record relevant information from family at referral and admission
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.
  Stated by The Langford CentreStated completed
2. Action
  Require staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.
  Stated by The Langford CentreStated completed
3. Action
  Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
  Stated by The Langford CentreStated completed
1. Action
  Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
  Stated by NHS EnglandStated completed
2. Action
  Increase the role of family voice in the inpatient transformation programme.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Obtaining information from an informal patient’s family depends on the patient’s consent.
  Stated by The Langford CentreUnable to act
1. Position
  The Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Christopher Richard ALLUM · 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

Christopher Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.

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 seek and record relevant information from family at referral and admission
Wider context from the report
“Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care. Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan. ”
Source location
Christopher Richard ALLUM · 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
Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.

Verbatim wording from the response
“b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

Source location
Response from Bramley Health
Page 2 · response
Published 14 November 2023
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
Require staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.

Verbatim wording from the response
“If agreed, a qualified member of staff is subsequently tasked with reaching out to the family and recording vital information. The document includes a section to record the information provided by a family or relative. Obtaining contact information and speaking with the next of kin are now a mandatory task at Langford.”

Source location
Response from Bramley Health
Page 3 · response
Published 14 November 2023
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
Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.

Verbatim wording from the response
“Finally, as there have been amendments to our initial processes, training updates have been rolled out company wide. This includes training to staff who triage our initial referral documents, medical doctors who conduct the initial assessments and consultants who oversee our ward rounds and MDT’s. All staff have been fully informed of the additional processes and the sensitivities surrounding the nature and detail of the information being requested.”

Source location
Response from Bramley Health
Page 3 · response
Published 14 November 2023
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
Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.

Verbatim wording from the response
“Christopher’s case does highlight the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. That is why joined up partnership working is one of the four key principles underpinning NHS England’s guidance on Acute inpatient mental health care for adults and older adults that was published in July 2023. This document provides specific advice on good practice on information sharing as well as guidance on the holistic assessment that should take place when someone enters a new facility, including identifying any safeguarding or risk issues, including risk to self and others. This includes guidance on the key actions that should take place within 72 hours of admission which include:”

Source location
Response from NHS England
Page 2 · response
Published 14 November 2023
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
Increase the role of family voice in the inpatient transformation programme.

Verbatim wording from the response
“In 2022, NHS England also established its Mental Health, Learning Disability and Autism Inpatient Transformation Programme to support cultural change and”

Source location
Response from NHS England
Page 2 · response
Published 14 November 2023
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
Obtaining information from an informal patient’s family depends on the patient’s consent.

Verbatim wording from the response
“b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

Source location
Response from Bramley Health
Page 2 · response
Published 14 November 2023
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 Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.

Verbatim wording from the response
“The Langford Centre is operated by Bramley Healthcare, an independent Mental Health Care Provider providing services within the South of England. I note that you have also addressed your Report to the Centre, and they would be the appropriate organisation to respond to the above concerns. NHS England will carefully review and consider their response to you.”

Source location
Response from NHS England
Page 1 · response
Published 14 November 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to obtain and consider relevant previous medical history

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to demonstrate professional curiosity and obtain relevant information from family members

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to include available family members in clerking patients with dementia

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to elicit additional risk information from patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Concerns raised2

Lack of professional curiosity about drug-taking and its clinical contribution

Failure to share relevant presentation information with family

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 1

Actions described in response 3

Actions described in response 3

Actions described in response 2

Actions described in response 9

Actions described in response 1

Respondent positions 1