Recurring concern

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

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First reported 27 Oct 2014•Latest report 18 Jun 2025

Definition

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.

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: 13
Individual concerns: 13
Date range: 2014–2025
Stated actions: 24

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.

Department of Health and Social Care3

Care Quality Commission2

1st Care 4U Ltd1

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Barts Health NHS Trust1

Boldmere Court Care Home1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

East London NHS Foundation Trust1

Greater Manchester Mental Health NHS Foundation Trust1

HM Prison and Probation Service1

HM Prison Service1

Holcroft Grange1

Mersey and West Lancashire Teaching Hospitals NHS Trust1

Minster Care Management Limited1

Southport and Ormskirk Hospital NHS Trust1

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.

29 Nov2016
South Yorkshire (Eastern)
Concerns raised1
1. Lack of effective communication between mental health professionals, patients and patients' families
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.
Actions described in response 2
1. Action
  Deliver Triangle of Care awareness sessions to Intensive Community Therapies Team staff.
  Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated planned
2. Action
  Review the Patient and Public Engagement Strategy to strengthen communication and involvement of carers.
  Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated completed
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 Feb2016
South Yorkshire (Eastern)
Concerns raised1
1. Lack of guidance for communicating with children with disabilities such as autism
This report raised 11 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
  Review the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completed
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
27 Oct2014
Manchester South
Concerns raised1
1. Poor communication between hospital staff and patients and families
This report raised 12 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
  Create and provide a bedside patient-safety booklet explaining acute-illness recognition and monitoring for patients and relatives.
  Stated by Tameside General HospitalStated completed
2. Action
  Remind professional staff to communicate proactively and effectively with patients’ families.
  Stated by Tameside General HospitalStated completed
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

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

Lack of guidance for communicating with children with disabilities such as autism

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

Poor communication between hospital staff and patients and families

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

Actions described in response 2

Actions described in response 1

Actions described in response 2