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.

28 Jan2015
Surrey
Concerns raised1
1. Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave
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.

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

Katherine Liana Bonaventura · 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

Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.

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 a system for sufficiently thorough private consultation with family members or carers after inpatient leave
Wider context from the report
“It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”
Source location
Katherine Liana Bonaventura · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Aug2014
Inner North London
Concerns raised1
1. Failure to directly assess thoughts of taking one's life
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 3
1. Action
  Update the clinical risk assessment and management policy.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Raise with supervisors that risk-assessment content must be checked during supervision.
  Stated by North London NHS Foundation TrustStated planned
3. Action
  Instruct clinical staff to assess risks to self and others and address identified risks in care plans.
  Stated by North London NHS Foundation TrustStated planned
AI-generated summary

Noleen Mary McPHARLANE · 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

Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.

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 directly assess thoughts of taking one's life
Wider context from the report
“1. Ms McPharlane had a long history of overdoses and self inflicted wounds, her last admission to hospital for treatment for the consequent physical injuries being in May 2013. However, in the year following that until her death, the clinical specialist who looked after never once asked her directly if she had thoughts of taking her life. ”
Source location
Noleen Mary McPHARLANE · 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
Update the clinical risk assessment and management policy.

Verbatim wording from the response
“The Trust has a clinical risk assessment and management policy in place. It has been reviewed and updated in September 2014 and is currently being consulted upon. The Trust believes that effective risk assessment and management is crucial to the delivery of high quality services across all parts of the Trust and is a core component of mental”

Source location
2014-0370-Response-by-Camden-Islington-NHS
Page 1 · response
Published 7 August 2014
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
Raise with supervisors that risk-assessment content must be checked during supervision.

Verbatim wording from the response
“The Head of the Personality Disorders Service will raise with supervisors in the service that the content of risk assessments are checked during supervision.”

Source location
2014-0370-Response-by-Camden-Islington-NHS
Page 4 · response
Published 7 August 2014
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
Instruct clinical staff to assess risks to self and others and address identified risks in care plans.

Verbatim wording from the response
“The Director of Nursing & People and the Interim Medical Director will ensure that all clinical staff are instructed to ensure that the risk assessments of all services users include asking about risks to self and others and, if risks are identified, that these are addressed in care plans. The deadline for this is November 2014.”

Source location
2014-0370-Response-by-Camden-Islington-NHS
Page 4 · response
Published 7 August 2014
Open published response
20 Jun2014
Suffolk
Concerns raised1
1. Failure to obtain relevant medical information for care planning during initial reception assessment
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.

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

Redmond Johnson · 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

Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain relevant medical information for care planning during initial reception assessment
Wider context from the report
“(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison service. ”
Source location
Redmond Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 May2014
Blackpool and the Fylde
Concerns raised1
1. Failure to obtain relevant family medical history from patients
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.
Respondent positions 1
1. Position
  Familial history was obtained, and its absence at admission did not materially affect disease-risk assessment or treatment.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Linda Yvonne Fisher · 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

Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.

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 relevant family medical history from patients
Wider context from the report
“2. The inquest also heard evidence that other members of the Deceased’s family had suffered from a similar condition. There were no records to suggest that this relevant information had been obtained by medical staff following her admission, and therefore nor had it been communicated effectively to other staff who may in due course have had involvement in her care. I am concerned that if such information is not obtained appropriately from patients and is not communicated effectively to other hospital staff then decisions pertaining to clinical care may be made erroneously and future deaths may result. ”
Source location
Linda Yvonne Fisher · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Familial history was obtained, and its absence at admission did not materially affect disease-risk assessment or treatment.

Verbatim wording from the response
“2) That a familial history of disease was not recorded in the notes.”

Source location
2014-0226-Response-by-Blackpool-Teaching-Hospitals
Page 2 · response
Published 9 May 2014
Open published response
31 Mar2014
London (East)
Concerns raised1
1. Failure of nursing staff to establish a fallen patient’s medical and medication 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.

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

Roy Joseph Godfrey · 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

Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

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 nursing staff to establish a fallen patient’s medical and medication history
Wider context from the report
“5. The Deputy Manager confirmed that the qualified member of staff who attended when Mr Godfrey sustained his fall should have been aware of the increased risk of bleeding as a result of the long term warfarin. She confirmed that he may not have had access to the medication chart. It is my view that a qualified member of the nursing staff who attends a patient who has suffered a fall should make themselves aware of both the patient’s medical history and medication history. ”
Source location
Roy Joseph Godfrey · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave

Concerns raised1

Failure to directly assess thoughts of taking one's life

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 obtain relevant medical information for care planning during initial reception assessment

Concerns raised1

Failure to obtain relevant family medical history from patients

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

Concerns raised1

Failure of nursing staff to establish a fallen patient’s medical and medication history

Actions described in response 3

Respondent positions 1