Recurring concern

Incomplete clinical history-taking

First to latest report 31 Mar 2014 — 31 Oct 2025

Reports that mention this concern
55
Times this concern has been raised
58
Stated actions linked to this concern
96

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.

What is 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 and published responses 55 reports

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

  1. South Wales Central

    AI-generated summary

    Mrs Ruth Ellen Edwards · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate risk history-taking during clinical consultation

    Wider context from the report

    “(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. ”

    Source location

    Mrs Ruth Ellen Edwards · 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

    Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.

    Verbatim wording from the response

    “The care and attention to detail taken by doctors and other healthcare professionals when taking histories and information from mental health patients.”

    Source location

    2018-0395-Response-by-University-Health-Board
    Page 3 · response
    Published 17 May 2019

    Open published response

  2. Manchester West

    AI-generated summary

    Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain collateral histories during Mental Health Act assessments

    Wider context from the report

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

    Source location

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

    Open source report

  3. Black Country

    AI-generated summary

    Mr Colin Johns · 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 Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate communication and history-taking during mental health assessment

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse. Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley. ”

    Source location

    Mr Colin Johns · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    William Henry BERGMAN · 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

    William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.

    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 detailed symptom information after head injury

    Wider context from the report

    “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

    Source location

    William Henry BERGMAN · 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

    Introduce a formal trust-wide policy for managing head injury in patients and staff.

    Verbatim wording from the response

    “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

    Source location

    2017-0343-Barts-NHS-Trust
    Page 1 · response
    Published 4 February 2018

    Open published response

  5. North West Wales

    AI-generated summary

    Simon Willans · 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

    Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.

    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 family history of pulmonary embolism

    Wider context from the report

    “(5) The history recovered by Nurse Practitioner ████████ is inadequate in that it did not elicit family history of Pulmonary Embolism ”

    Source location

    Simon Willans · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Black Country

    AI-generated summary

    Mrs Lily Townsend · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Lily Townsend fell at home, was admitted to hospital with a fractured neck of femur, and died during cemented hemiarthroplasty after her oxygen saturation and blood pressure fell rapidly. Concerns included inadequate recording of her medical history, failure to identify her as being at extremely high risk for major surgery, inadequate consent, and whether an un-cemented operation might have reduced the 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

    Inadequate preoperative medical history-taking and recording

    Wider context from the report

    “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension. 2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given. 3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement. 4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk. b) Consent process inadequate. ”

    Source location

    Mrs Lily Townsend · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Brighton and Hove

    AI-generated summary

    Trevor John CURRY · 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

    Trevor John CURRY died within 48 hours of admission to a psychiatric hospital. The concerns were that information about his heart problems was not recorded in his admitting note and that the trust did not obtain his full physical medical history until after his death, with particular concern about timely access to medical histories for psychiatric patients unable to provide them.

    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 ascertain and access patients’ full past medical histories promptly

    Wider context from the report

    “(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories. In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself. ”

    Source location

    Trevor John CURRY · 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

    Operate a system requiring primary care records for new acute admissions within 48 hours, verifying requests and uploading records to Carenotes.

    Verbatim wording from the response

    “In relation to the timely requests for primary care records and information about our patients, I am pleased to say a new system has been introduced. The new system, now in use is as follows; The Crisis Resolution and Home Treatment Team administrators request a copy of the primary care, summary care record, or encounter report, from the GP”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 1 · response
    Published 23 February 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

    Circulate and display primary-care-information guidance and provide it to new junior doctors through induction materials.

    Verbatim wording from the response

    “practice for all new patients admitted to Mill View hospital. This is done within 48 hours of admission and the administrators verify all new patient admissions at the daily Acute Referral Meeting (ARM) which is attended by the Bed Manager. The Crisis Resolution and Home Treatment Team administrators upload the primary care, summary care record / encounter report to the Trust’s electronic health records system ‘Carenotes’ which all clinical staff in the Trust have access to. Laminated copies of the guidance has been circulated to the wards at Mill View Hospital and it is displayed for staff as a reminder and for easy reference. Please find enclosed our new Protocol for the Management of Primary Care Clinical Information for all Patients admitted to acute inpatient services for your information.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 23 February 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

    Develop an opt-out system informing patients that summary care record access will occur by default, subject to stated exceptions.

    Verbatim wording from the response

    “In addition, ████████ (Chief Pharmacist) produced guidance for staff regarding the importance of obtaining the primary care, summary care record, which was distributed to Trust staff and taken to staff meetings for sharing and discussion. Clinicians in both primary and secondary care can access summary care records using an NHS Smartcard, once they are set up on the national system. Furthermore, the Trust is currently looking to establish an “opt out” system so that patients in contact with our services are informed that summary care record access will occur by default unless they specify that it may not, (unless a best interest decision needs to be made). ████████ (Chief Pharmacist) has confirmed that this guidance is now included in the induction pack for all new junior doctors joining the Trust.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 23 February 2024

    Open published response

  8. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 update patients’ risk history and assessment

    Wider context from the report

    “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Tedros Habtom KAHSSAY · 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

    Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

    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 explore recorded history of depression during reception screening

    Wider context from the report

    “6. The second reception (well man) screening nurse did not explore the history of depression recorded, he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it. ”

    Source location

    Tedros Habtom KAHSSAY · 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

    Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.

    Verbatim wording from the response

    “We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 2 · response
    Published 6 December 2016

    Open published response

  10. East London

    AI-generated summary

    Peter Daniel Usher · 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

    Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

    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 communicate relevant police and family information during admission

    Wider context from the report

    “4. The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received. This was not passed on to the hospital staff. It became apparent during the course of the Inquest that the police also had access to information which was relevant to the circumstances of the preceding events which would have been relevant to the mental state of the deceased. It would appear that inadequate questions were asked by the receiving hospital team in relation to the circumstances leading to admission. ”

    Source location

    Peter Daniel Usher · 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 s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.

    Verbatim wording from the response

    “1, 2, 3, 4 | With emphasis on the requirement to comply with:”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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 generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.

    Verbatim wording from the response

    “9 | To create a generic and secure nhs.net account for s136 suite, which would be monitored and used by the bleep holders to receive the collateral | OJ/VP/RK | 31.03.2017”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    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

    Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.

    Verbatim wording from the response

    “1.1 – The s136 paperwork completed by officers on the street is Form 434. The form has two particular areas that by their description can create ambiguity when completing them. The first is towards the top where it has the words “Friends/Family” and a space adjacent to it for the officer to fill out. I believe this needs to be more specific and should be changed to “Next of Kin.” This will give the officers more clarity when completing the form and eliminating the potential risk of important information being missed. The second is further down and reads “Name of person handing over” then as above there is a space adjacent for the officer to complete. This leaves some doubt as to whether the person accepting responsibility needs to sign. Under the s136 Pathway it clearly states that a signature is required.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 2017

    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

    Design a bespoke handover form with NELFT for use at the 136 suite.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 2017

    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

    Hold a progress-review meeting on the bespoke handover form.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026