Recurring concern

Failure to ensure care staff can communicate effectively with residents and patients

First to latest report 27 Oct 2014 — 18 Jun 2025

Reports that mention this concern
13
Times this concern has been raised
13
Stated actions linked to this concern
24

What this concern includes

Includes failures in direct care-staff communication with residents or patients that impair understanding of instructions, expression of needs, recognition of risks or safe delivery of care, including agency staff and communication with highly vulnerable patients.

What is not included
  • Excludes generic organisational communication, inter-agency information sharing and professional-to-professional handover failures where direct communication between care staff and residents or patients is not the unsafe condition.
  • Excludes interpreter-access, translation-service and multilingual communication failures where the principal deficiency is provision of language support rather than the care staff's direct communication capability.
  • Excludes failures limited to communicating policies or protocols to staff, or to patient-facing letters and appointment notices, when direct care interaction is not deficient.
  • Excludes generic staffing, training or English-language deficiencies unless they directly impair safe communication between care staff and residents or patients.

Reports and published responses 13 reports

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

  1. South Yorkshire (Eastern)

    AI-generated summary

    John Atkinson · 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

    John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.

    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 effective communication between mental health professionals, patients and patients' families

    Wider context from the report

    “(4) Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient’s family. ”

    Source location

    John Atkinson · 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

    Deliver Triangle of Care awareness sessions to Intensive Community Therapies Team staff.

    Verbatim wording from the response

    “The Trust has attempted to address the issue of communication and coproduction between patients, carers and staff over the last few years and therefore it is particularly disappointing that this issue has again been raised as a concern. For example you may recall from previous formal communications, that the Trust launched the “Triangle of Care” initiative during 2015 which is a National Programme to bridge the gap between professionals and carers. This initiative has been successfully implemented within the Rotherham inpatient wards therefore we have initiated increased awareness sessions to be delivered to the ICT staff group on 24 January and 9 February 2017. The sessions are delivered by carers and have been successful in reducing inpatient carer related complaints.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 5 · response
    Published 12 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

    Review the Patient and Public Engagement Strategy to strengthen communication and involvement of carers.

    Verbatim wording from the response

    “The Trust has recently reviewed its Patient and Public Engagement Strategy which includes an expectation that staff involve and communicate with carers, a further enhancement of the Triangle of Care work.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 6 · response
    Published 12 February 2017

    Open published response

  2. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 guidance for communicating with children with disabilities such as autism

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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 the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.

    Verbatim wording from the response

    “With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response

  3. Manchester South

    AI-generated summary

    Agnes Mary Hannan · 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

    Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

    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

    Poor communication between hospital staff and patients and families

    Wider context from the report

    “3. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst hospital staff. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate. ”

    Source location

    Agnes Mary Hannan · 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

    Create and provide a bedside patient-safety booklet explaining acute-illness recognition and monitoring for patients and relatives.

    Verbatim wording from the response

    “Response The Trust is striving to improve communication between staff and family members. The Trust has created a bedside booklet available for patients and relatives – “Patient Safety – Keeping you safe during your stay in hospital”. This includes a section on recognising acute illness and how this is monitored and empowers patients and their families to ask questions. Professional staff have been reminded of their duties to communicate proactively and effectively.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 27 October 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

    Remind professional staff to communicate proactively and effectively with patients’ families.

    Verbatim wording from the response

    “Response The Trust is striving to improve communication between staff and family members. The Trust has created a bedside booklet available for patients and relatives – “Patient Safety – Keeping you safe during your stay in hospital”. This includes a section on recognising acute illness and how this is monitored and empowers patients and their families to ask questions. Professional staff have been reminded of their duties to communicate proactively and effectively.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 27 October 2014

    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