Recurring concern

Unsafe reliance on clinical questionnaires during patient assessment

First to latest report 25 Oct 2016 — 18 Nov 2025

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
10

What this concern includes

Includes failures in the design, use, completion, review or clinical interpretation of questionnaires or proformas used for patient assessment where mechanical, rote or excessive reliance can impede diagnosis, risk evaluation, reconciliation of information or communication of concerns.

What is not included
  • Excludes generic clinical assessment or diagnostic-reasoning failures where no questionnaire or proforma is a material part of the unsafe condition.
  • Excludes failures of named systems such as NEWS or the Manchester Triage System when that system supplies the more specific supported parent boundary.
  • Excludes ordinary documentation omissions where the questionnaire or proforma did not contribute to the unsafe condition.
  • Excludes generic staffing, workload or training deficiencies unless they directly cause unsafe reliance on or completion of a clinical questionnaire or proforma.

Reports and published responses 5 reports

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

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Dominic Edward Arthur HURLEY · 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

    On 8 July 2024, Dominic Hurley became unwell during an offshore dive, made a rapid uncontrolled ascent, became unconscious, and later died in hospital. The principal concern was that he had not disclosed a previous serious diving incident and cardiac history when renewing his diving licence, with reliance on self-declaration questionnaires without further enquiry or access to previous medical history identified as a potential risk.

    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

    Overreliance on self-declaration questionnaires without further enquiry or access to previous medical history

    Wider context from the report

    “In 2018 Mr Hurley suffered shortness of breath and pulmonary oedema during a dive in Malta. This led to him having a heart bypass on his return to the UK. There was significant family history of cardiac related issues. Time passed but in 2021 and 2023 Mr Hurley sort to renew his diving licence. Mr Hurley completed his self declaration questionnaire. At no stage did he declare the events in 2018 in relation to his dive and nor did he discuss this with the Dr assessing him. It is likely that he Dr been aware of the previous diving incident a different course of action may have taken. There is currently too much reliance placed on the self declaration questionnaire without any further enquiry or access to previous medical history. This leads to a false sense of reality and put the diver and others at potential risk of death on further dives. ”

    Source location

    Dominic Edward Arthur HURLEY · 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

    Include immersion pulmonary oedema in the diving medical screening declaration.

    Verbatim wording from the response

    “The SAA use the medical screening system managed by the UKDMC (United Kingdom Diving Medical Committee) (https://www.ukdmc.org/). I have checked my medical form archive and note that “immersion induced pulmonary oedema” was introduced in the May 2020 version of the declaration at question 17. The current version, May 2024, of the form has this at question 16.”

    Source location

    Response from Sub Aqua Association Space Solutions Business Centre
    Page 1 · response
    Published 19 November 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

    Remind members at renewal and through periodic newsletters to complete medical declarations accurately.

    Verbatim wording from the response

    “I believe that the SAA has advised its membership and revised their training programme in such a manner as to have already implemented the changes required to mitigate the risk of IPO when diving, in so far as any risk can be mitigated. However, the SAA will ensure that the membership is reminded of the importance of accurately completing medical by emphasising the fact at renewal and with periodic reminders in their newsletters.”

    Source location

    Response from Sub Aqua Association Space Solutions Business Centre
    Page 2 · response
    Published 19 November 2025

    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

    Revised medical screening forms and existing training changes are considered sufficient to mitigate the risk of immersion pulmonary oedema in diving.

    Verbatim wording from the response

    “I believe that the revision to the current dive medical screening forms now meet the change you are now seeking to make.”

    Source location

    Response from Sub Aqua Association Space Solutions Business Centre
    Page 2 · response
    Published 19 November 2025

    Open published response

  2. South Wales Central

    AI-generated summary

    Peter Malcolm THOMAS · 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 Malcolm Thomas, aged 78, was admitted with a serious infection and delirium after collapsing, but was treated under the CIWA protocol after giving an erroneous account of alcohol use. He received 80 mg of diazepam over six hours, did not regain consciousness after antidote treatment, and died from bronchopneumonia associated with osteomyelitis and peripheral vascular disease. The principal concerns were that CIWA may not account adequately for age, delirium, confusion, metabolic differences, or lack of collateral information, and that its use could result in unnecessary high-dose sedation and future deaths.

    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 CIWA protocol to account for advancing age, different metabolic rate, delirium, confusion and lack of collateral evidence

    Wider context from the report

    “(1) I am concerned that the CIWA protocol is something of a blunt instrument, not at all nuanced to take account of for example, advancing age and different metabolic rate, delirium and confusion and lack of collateral evidence ”

    Source location

    Peter Malcolm THOMAS · 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

    Reconsider the alcohol-withdrawal guidance, including CIWA-Ar and pharmacological treatment, at the February–March 2026 prioritisation board meeting.

    Verbatim wording from the response

    “In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 16 September 2025

    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

    Existing recommendations adequately convey the need for professional skill in assessing and monitoring acute alcohol withdrawal.

    Verbatim wording from the response

    “Our opinion is that these recommendations adequately convey the need for professional skill in the assessment and monitoring of patients and in the application of our recommendations.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 1 · response
    Published 16 September 2025

    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

    Individual clinicians retain responsibility for treatment decisions and applying guidance appropriately to each patient’s circumstances.

    Verbatim wording from the response

    “As background regarding the status of NICE guidelines, it is important to note that the recommendations in our guidelines represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals and practitioners are expected to take NICE guidelines fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory for the NHS to apply the recommendations, and the guideline does not override the responsibility for clinicians to make decisions appropriate to the circumstances of the individual, in consultation with them (and their families and carers or guardian where appropriate).”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 16 September 2025

    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

    NICE cannot amend the CIWA-Ar protocol because it was not produced by NICE.

    Verbatim wording from the response

    “In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 16 September 2025

    Open published response

  3. Brighton and Hove

    AI-generated summary

    John Michael KIRBY · 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 Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.

    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

    Inappropriate ADHD assessment and prescribing suggestion

    Wider context from the report

    “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

    Source location

    John Michael KIRBY · 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

    Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.

    Verbatim wording from the response

    “As your concern centres on clinical decision-making I asked the Trust’s Chief Medical Officer ████████ to set up a group of senior medical colleagues to review ████████ medical practice in relation to ADHD. The terms of reference of that medical decision-making group (DMG) included consideration of the use of ADHD questionnaires for diagnosis as well as consideration of the assessment and diagnosis of ADHD and recommended prescribing.”

    Source location

    2018-0379-Response-by-Sussex-NHS-Trust
    Page 2 · response
    Published 12 May 2019

    Open published response

  4. Inner West London

    AI-generated summary

    Maximilien Conrad Kohler · 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

    Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.

    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

    Over-reliance on questionnaires impeding correct diagnosis

    Wider context from the report

    “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular. ”

    Source location

    Maximilien Conrad Kohler · Prevention of Future Deaths report
    Page 3 · 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

    Over-reliance on questionnaires causing underestimation of self-harm risk

    Wider context from the report

    “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular. ”

    Source location

    Maximilien Conrad Kohler · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Richard Walsh · 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

    Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    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 consider the whole person and reconcile or communicate missing and discordant information during proforma completion

    Wider context from the report

    “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”

    Source location

    Richard Walsh · 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 AMHP guidance requiring direct scrutiny of police custody records and logs.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 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

    Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 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

    Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.

    Verbatim wording from the response

    “The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 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

    Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.

    Verbatim wording from the response

    “HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 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

    Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.

    Verbatim wording from the response

    “The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 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 professional development opportunities for AMHPs conducting police-custody assessments.

    Verbatim wording from the response

    “5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 4 · response
    Published 26 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