Recurring concern

Unreliable handover of care information and responsibility

First to latest report 17 Jan 2014 — 26 Jun 2026

Reports that mention this concern
45
Times this concern has been raised
48
Stated actions linked to this concern
77

What this concern includes

Includes failures in the dedicated handover process for care information or responsibility, including absent or unclear procedures, incomplete or unauditable handover records, failure to transfer relevant information, and unclear or uncompleted handovers between care staff, managers, coordinators or successor services.

What is not included
  • Excludes clinical handovers between healthcare professionals where the existing clinical-handover concern is the more specific supported boundary.
  • Excludes failures of discharge, inter-service transfer or general continuity processes where no care-handover deficiency is identified.
  • Excludes generic communication, staffing, documentation or training deficiencies unless they directly impair the transfer of care information or responsibility during handover.
  • Excludes non-care operational handovers, such as fire-and-rescue incident roles or general workplace shifts, unless the assertion concerns transfer of responsibility for care.

Reports and published responses 45 reports

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

  1. East Riding and Hull

    AI-generated summary

    Susan Dale · 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

    Susan Dale, a resident of Westfields Residential Home, fell while being assisted with her morning routine on 8 April 2026 and later deteriorated, was taken to hospital, and died on 18 April 2026. The principal concerns were inaccurate and inconsistent records about the fall, moving her despite a recorded possible head injury without prompt clinical assessment, and the absence of an effective handover to staff taking over her care.

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    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 provide handover information between care shifts

    Wider context from the report

    “(3) The senior care worker who came on shift later that day said she did not receive any hand over from the staff going off shift. This is a concern as observations need to be carried out when someone has fallen and banged their head and a handover would detail such incidents and whether there are any concerns with residents. ”

    Source location

    Susan Dale · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Replace the paper diary with a structured handover process providing staff with shared resident information.

    Verbatim wording from the response

    “A new structured handover process is now replacing the old paperback diary format at Westfield ensuring all members of staff can access the same information readily, to ensure all staff are well educated on each residents health.”

    Source location

    Response from Westfield Residential Home
    Page 2 · response
    Published 2 September 2026

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    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

    Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.

    Verbatim wording from the response

    “Following receipt of the Regulation 28 Report, CQC have initiated a review of this incident in line with our specific incident guidance. CQC also conducted an unannounced inspection of Westfield Residential Home on 21 July 2026. The matters of concern highlighted in the Regulation 28 Report helped to inform our inspection activity and ensure there was a particular focus on record keeping, safe management of falls and handover processes.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 2 September 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.

    Verbatim wording from the response

    “During our unannounced inspection, in respect of any ongoing risk posed to service users, CQC did not identify any issues relating to the matters of concern raised that would require any regulatory action.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 2 September 2026

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    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

    Inspection evidence identified no concerns with handover processes between staff.

    Verbatim wording from the response

    “In relation to our recent inspection of the service last month, we reviewed handover processes as part of our assessment of whether the service was providing safe care and treatment to all who use the service. Evidence available and gathered in relation to handover processes between staff did not identify any concerns.”

    Source location

    Response from Care Quality Commission
    Page 4 · response
    Published 2 September 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Rickie Wai Kee POON · 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

    Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.

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    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 complete handovers between ACCT staff

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

    Verbatim wording from the response

    “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 10 April 2026

    Open published response

  3. West Sussex, Brighton and Hove

    AI-generated summary

    John Malcolm 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

    John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.

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    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 provide complete current medication and stop-date information during care handover

    Wider context from the report

    “3) UCR then arranged for a care agency, Coastal Homecare, to take over supporting Mr Fisher. During the inquest I saw a referral from prepared by UCR confirming that Coastal Homecare were required to assist Mr Fisher three times a day to help with his personal care and medicine administration. However, the only medication information that was supplied by the UCR team to Coastal Homecare referred to blister packs and liquid medication including antibiotics for chest infection. No further details of current regular medication, dosage, timing or form of medication (eg blister pack, separate boxes or liquids) were provided at all. In addition, the antibiotics were only for a short number of days but no clear indication is given when they were to stop and may well have finished by the time Coastal took over care. ”

    Source location

    John Malcolm FISHER · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.

    Verbatim wording from the response

    “• Clear escalation pathways have been strengthened, including referral to senior clinicians and SCFT pharmacy support for complex medicines reconciliation.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide staff with Plexus shared-care-record access for real-time GP medication summaries.

    Verbatim wording from the response

    “• Since October 2025, SCFT staff have access to shared care records via the Plexus system (which links digital care records across Sussex GP’s, hospital and community healthcare services as well as local authorities), enabling real-time access to GP medication summaries and reducing reliance on emailed or static information.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.

    Verbatim wording from the response

    “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    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

    Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.

    Verbatim wording from the response

    “• SCFT has strengthened expectations within referral pathways that medicines reconciliation must be confirmed at transitions of care, particularly where responsibility for medicines administration is transferring.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    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 staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.

    Verbatim wording from the response

    “The following changes have now been implemented:”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.

    Verbatim wording from the response

    “• At the time Mr Fisher was receiving support from our service, GP Connect access was not available to our digital platform. Since October 2025, we have fully integrated GP Connect to our digital platform, and into current practice as an additional safeguard to support safer medication management and continuity of care. Subject to appropriate consent arrangements and patient opt-out rights, authorised staff are now able to review GP medication summaries to verify prescribed medicines and identify recent medication changes during referral, assessment, and handover processes. This has strengthened our ability to cross-check medication information and identify discrepancies at an early stage.”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    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

    Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.

    Verbatim wording from the response

    “We recognise, however, that some medication changes initiated within hospital settings, Urgent Community Response services, or other secondary care pathways may not always be immediately reflected within GP Connect records. Our revised procedures therefore also require liaison with relevant healthcare professionals, including pharmacists, and specialist teams, where appropriate, to support safe and accurate medication management.”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    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

    Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.

    Verbatim wording from the response

    “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    Open published response

  4. Dorset

    AI-generated summary

    James Fitzpatrick · 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

    James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.

    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 written local guidance for undertaking and recording handovers

    Wider context from the report

    “(3) Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the Trust. ”

    Source location

    James Fitzpatrick · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and take SBAR-based inpatient handover guidance through internal governance.

    Verbatim wording from the response

    “We are committed to ensuring that the development and implementation of the new pan-Dorset electronic health record in 2028 prioritises a robust, accurate, and live handover function to support safe and consistent practice across all services.”

    Source location

    2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
    Page 2 · response
    Published 13 February 2026

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    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

    Scope handover processes across all mental health inpatient units by June 2026 to identify required changes.

    Verbatim wording from the response

    “Alongside this immediate action to develop this guidance we have adopted a focus on handovers as a Trust Quality Priority for 2026/27. As part of this work, the first action is to scope the handover processes across all mental health inpatient units by June 2026. This will allow us to understand current approaches, the reasoning behind them, and what changes are required in light of the learning from this inquest whilst we await the new electronic health record. Establishing the Quality Priority for “Improving Inpatient and Transfer of Care Handovers”, means that audits of any incidents relating to concerns regarding handover processes will be reviewed and reported through the Directorate Management Groups for oversight and assurance. The auditing processes will be undertaken between June 2026 and March 2027.”

    Source location

    2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
    Page 3 · response
    Published 13 February 2026

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    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

    Detailed handover guidance for every healthcare facility would be impractical for a central organisation and unsuitable for differing local contexts.

    Verbatim wording from the response

    “We believe that detailed specific guidance for every individual healthcare facility on patient handover would be very challenging for a central organisation to produce and would not be well adapted to the local setting and context. Instead, each organisation should produce local, relevant guidance based on the resources outlined above.”

    Source location

    2026-0087 - Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 13 February 2026

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    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

    DHUFT is responsible for addressing the lack of written local handover guidance or policy.

    Verbatim wording from the response

    “3. Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded This area of concern is for DHUFT to respond to.”

    Source location

    2026-0087 - Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 13 February 2026

    Open published response

  5. Coventry

    AI-generated summary

    Wayne Pierce Walton · 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

    Wayne Pierce Walton was discharged from the Caludon Centre on 21 June 2024 after taking an overdose with the intention of ending his life. He failed to engage consistently with the Home Treatment Team and died by asphyxiation on 29 June 2024. Concerns included inadequate completion and transfer of risk assessment and safety plan information, and a lack of guidance on potential conflicts of interest involving staff who recognised a patient outside the circumstances covered by an existing policy.

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    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 pass important risk information to the Home Treatment Team

    Wider context from the report

    “(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”

    Source location

    Wayne Pierce Walton · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.

    Verbatim wording from the response

    “Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystemOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all.”

    Source location

    2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
    Page 1 · response
    Published 21 January 2026

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    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

    Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.

    Verbatim wording from the response

    “Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis.”

    Source location

    2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
    Page 2 · response
    Published 21 January 2026

    Open published response

  6. Derby and Derbyshire

    AI-generated summary

    Peter William THOMPSON · 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 William Thompson, who had Type 2 Diabetes and had moved into residential care after worsening mobility, became ill with a urinary tract infection, reduced food and fluid intake, swallowing difficulties and refusal of medication. His blood sugar levels were not tested until paramedics attended on 5 March 2025, by which time he had developed Hyperglycaemic Hyperosmolar State and severe kidney damage; he died in hospital on 9 March 2025. The principal concerns were the absence of blood sugar testing by care home staff and the lack of formal handovers between shifts, which could delay escalation of a resident’s deteriorating condition.

    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 conduct formal handovers between shifts

    Wider context from the report

    “2. I heard evidence from the former manager that handovers between shifts do not take place. That staff should look in an individual residents' records. Records do not provide a complete picture of a residents condition and in particular details of staff's ongoing concerns. The priority of the continuing concern about Peter's deterioration does not appear from the records to have been handed over between shifts. To not have a formal handover at the end and start of a shift gives cause for concern that there is a risk to future death. That delays are caused in escalating a resident's condition. ”

    Source location

    Peter William THOMPSON · 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

    Strengthen documentation requirements so verbal handover information is consistently and accurately recorded.

    Verbatim wording from the response

    “We acknowledge the coroner’s concern that the records reviewed during the inquest did not fully reflect the level of discussion or the priority of concerns during handover. In response, we have strengthened documentation expectations to ensure that all verbal handover information is consistently and accurately recorded.”

    Source location

    Response from Bank Close House Residential Care Home
    Page 1 · response
    Published 20 January 2026

    Open published response

  7. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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

    Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

    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 communicate relevant risk information through handovers and records

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”

    Source location

    Steven HART · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Strengthen shift handovers through clearer risk-information sharing expectations and allocated time for comprehensive handovers.

    Verbatim wording from the response

    “Handover procedures have also been strengthened to ensure that vital information is communicated effectively. Staff are supported through clearer expectations in relation to information sharing when there is evidence of a prisoners change to risk or presentation. Time has been allocated to facilitate comprehensive handovers between shifts, particularly in relation to those who are being supported by the Assessment, Care in Custody and Teamwork (ACCT) process.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

    Open published response

  8. West Yorkshire Eastern

    AI-generated summary

    Christian Barry · 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

    Christian Barry, who had recent alcohol withdrawal and worsening mental health symptoms, was found hanging in a bathroom at a respite facility on 6 January 2025 and was pronounced dead at the scene. The principal concern was the lack of a formal system for communication, information sharing and handover between the respite facility and the clinical service responsible for his care, including after a planned 48-hour review was missed.

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    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 formal system for communication, information sharing and handover between the respite facility and the Intensive Support Service

    Wider context from the report

    “There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and Yorkshire Partnership Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk. ”

    Source location

    Christian Barry · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Use a standardised daily handover template to capture clinical information, reviews, tasks, incidents, MDT comments and required follow-up.

    Verbatim wording from the response

    “1. Standardised Daily Handover and implementation of daily ‘huddle’ meeting”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 1 · response
    Published 19 September 2025

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    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 daily Oasis–CRISS huddle to discuss handover information and address immediate actions and queries.

    Verbatim wording from the response

    “Once completed, the handover sheet is emailed to the appropriate LYPFT Crisis Resolution Intensive Support Service (CRISS) team. There are three locality teams East, South, and West, and the handover is sent to the corresponding area in which the individual is currently receiving care. The shift coordinator within the CRISS team is responsible for accessing this information and ensuring this is taken for discussion in the daily ‘huddle’ meeting as described below.”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 2 · response
    Published 19 September 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

    Ensure CRISS shift coordinators bring Oasis handover information to each locality’s daily multidisciplinary team meeting.

    Verbatim wording from the response

    “2. Multidisciplinary Review Meetings”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 2 · response
    Published 19 September 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

    Record handover details and required actions in Oasis’s own system.

    Verbatim wording from the response

    “3. Documentation improvements”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 2 · response
    Published 19 September 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

    Add Oasis handover notes, MDT discussions and required actions to LYPFT care records.

    Verbatim wording from the response

    “• LYPFT adds Oasis handover notes to the patient’s LYPFT care record as well as a full record of the MDT discussion and any required action.”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 3 · response
    Published 19 September 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

    Provide training on the handover sheet, including each organisation’s roles and responsibilities.

    Verbatim wording from the response

    “5. Training and Governance”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 3 · response
    Published 19 September 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

    Monitor handover-process compliance and effectiveness through audits and feedback mechanisms.

    Verbatim wording from the response

    “5. Training and Governance”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 3 · response
    Published 19 September 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

    Explore Oasis staff access to LYPFT’s electronic patient record and discuss the proposal through the operations meeting.

    Verbatim wording from the response

    “In addition to the above, the CRISS team at LYPFT and Oasis staff are exploring the possibility of Oasis staff having access to LYPFT’s electronic patient record. This will be taken for further discussion through the operations meeting (described below).”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 3 · response
    Published 19 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 referral, admission, joint review, interface, operations and governance processes provide formal communication and risk-management arrangements.

    Verbatim wording from the response

    “We would also like to take this opportunity to describe the escalation processes and monitoring we currently have in place to ensure formal communication, risk management, and information sharing for patients admitted to the respite facility:”

    Source location

    Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
    Page 3 · response
    Published 19 September 2025

    Open published response

  9. South Yorkshire (Eastern)

    AI-generated summary

    Walter Colin HORTON · 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

    Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.

    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 maintain adequate discharge handover information

    Wider context from the report

    “(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

    Source location

    Walter Colin HORTON · 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 Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.

    Verbatim wording from the response

    “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
    Page 2 · response
    Published 19 September 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

    Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.

    Verbatim wording from the response

    “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

    Source location

    Response from Doncaster & Bassetlaw NHS Foundation Trust
    Page 2 · response
    Published 19 September 2025

    Open published response

  10. Worcestershire

    AI-generated summary

    Katrina Veronica Francesca Insley · 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

    Katrina Insley died on 1 January 2024 at Alexandra Hospital, Redditch, from sepsis due to an infected pressure sore and pneumonia. The report identified concerns about the absence of a formal, documented handover system between hospital and the Neighbourhood Team, limited access to hospital records, and the resulting risk of delayed recognition and treatment of pressure sores, infection and sepsis.

    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

    Absence of a formal, documented handover system between hospital and Neighbourhood Team

    Wider context from the report

    “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis. (2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed. ”

    Source location

    Katrina Veronica Francesca Insley · 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

    Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.

    Verbatim wording from the response

    “In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
    Page 2 · response
    Published 14 February 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

    Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.

    Verbatim wording from the response

    “In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
    Page 2 · response
    Published 14 February 2025

    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