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.

Trends

Reports over time

Reports mentioning this concern, 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

Essex Partnership University NHS Foundation Trust2

Herefordshire and Worcestershire Health and Care NHS Trust2

HM Prison and Probation Service2

National Institute for Health and Care Excellence2

Son of the deceased2

Sussex Partnership NHS Foundation Trust2

Worcestershire Acute Hospitals NHS Trust2

Arden Court1

Bank Close House1

Barts Health NHS Trust1

Bedford Prison1

Belle Green Court1

Betsi Cadwaladr University LHB1

Reports and published responses 45 reports

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

30 Oct2017
Worcestershire
Concerns raised1
1. Inadequate highlighting of particular patients' needs during handover
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Worcestershire Acute Hospitals NHS Trust
Stated actions 1
1. Worcestershire Acute Hospitals NHS Trust
  Use a standardized SBAR structure for clinical handovers across the hospital.
Respondent positions 1
1. Worcestershire Acute Hospitals NHS Trust
  The existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.
  Existing arrangements considered sufficient
AI-generated summary

Michael Edward Giles · 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

Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and medical records.

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
Inadequate highlighting of particular patients' needs during handover
Wider context from the report
“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”
Source location
Michael Edward Giles · 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
Use a standardized SBAR structure for clinical handovers across the hospital.

Verbatim wording from the response
“1. You’ve invited the Trust to consider standardising the handover process across the hospital and to put in place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised.”

Source location
2017-0309-Response
Page 1 · response
Published 28 November 2017
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
The existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.

Verbatim wording from the response
“The events surrounding this tragic case and your regulation 28 letter was discussed with the trainees in early November 2017. The conclusion from the trainees was that they were confident that the processes now in place were robust and they had not experienced any near misses as a consequence of inadequate handover. There is a standardised structure for handover which follows SBAR. This is an acronym for Situation, Background, Assessment, Recommendation. With reference to identifying a responsible person is a little more fraught. Handover takes place at multiple levels whilst the patient remains an inpatient.”

Source location
2017-0309-Response
Page 1 · response
Published 28 November 2017
Open published response
22 Jun2017
Inner South London
Concerns raised1
1. Failure to hand over urgent investigation needs to the responsible doctor
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

King'S College Hospital NHS Foundation Trust
Stated actions 3
1. King'S College Hospital NHS Foundation Trust
  Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
2. King'S College Hospital NHS Foundation Trust
  Establish Consultant-led virtual reviews of patients self-discharged during the take period to confirm investigations and follow-up are arranged.
3. King'S College Hospital NHS Foundation Trust
  Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
Respondent positions 3
1. King'S College Hospital NHS Foundation Trust
  The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
  Disputes the concern
1. King'S College Hospital NHS Foundation Trust
  Follow-up of proposed investigations is the responsibility of the team that ordered them, with the ordering team responsible for ensuring follow-up.
  Redirects responsibility
2. King'S College Hospital NHS Foundation Trust
  After self-discharge, ongoing care was assessed as transferring to the GSTT Palliative Care team, although MRI management would not ordinarily be its responsibility.
  Redirects responsibility
AI-generated summary

Constance Connolly · 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

Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from A&E.

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 hand over urgent investigation needs to the responsible doctor
Wider context from the report
“There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
Source location
Constance Connolly · 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
Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.

Verbatim wording from the response
“Steps have been taken to ensure that regardless of patients self-discharging, a formal Discharge Notification is always sent to a patient’s GP, setting out all relevant tests/assessments performed and any follow-up arrangements if applicable. Responsibility sits with the admitting Consultant and Ward Managers, and this will be included in the junior doctors’ induction information package.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 3 · response
Published 28 July 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 Consultant-led virtual reviews of patients self-discharged during the take period to confirm investigations and follow-up are arranged.

Verbatim wording from the response
“Finally, as mentioned above under Matter 1, the Trust is committed to ensuring the post-take Consultant undertakes a “virtual ward round” of any patient who has self-discharged during the take period, and reassures themselves they have received appropriate follow-up by way of signposting, appointments or otherwise.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 3 · response
Published 28 July 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
Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.

Verbatim wording from the response
“• The Trust is developing a Trust-wide best practice guide on Discharge Notification and clinic letter writing for clinical staff, in collaboration with the local CCGs. This will include clarification that a discharge notification is required for all patients who self-discharge.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 4 · response
Published 28 July 2017
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
The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.

Verbatim wording from the response
“As a preliminary point, we note that none of the concerns raised in the Report caused or contributed to Mrs Connolly’s death in light of the Conclusion reached at the Inquest hearing on 24 May 2017, namely “Natural causes contributed to by unintended consequences of necessary medical treatment”. The Report in particular states that no failures of care contributed to Mrs Connolly’s death.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 1 · response
Published 28 July 2017
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
Follow-up of proposed investigations is the responsibility of the team that ordered them, with the ordering team responsible for ensuring follow-up.

Verbatim wording from the response
“The Trust agrees follow-up of patients in terms of proposed investigations is the responsibility of the team who has ordered the investigation(s). An outpatient MRI scan appointment was made, but this should have been communicated more clearly to the GP. The “virtual review”, as described below under Matter 2, should facilitate clearer communication to health care colleagues, patients and families.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 2 · response
Published 28 July 2017
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
After self-discharge, ongoing care was assessed as transferring to the GSTT Palliative Care team, although MRI management would not ordinarily be its responsibility.

Verbatim wording from the response
“The referring doctor notified the GSTT Community Palliative Care team of the need to organise a MRI scan, on the understanding that the team was taking over care. The Consultant in the Palliative Care team explained that their role was to advise the doctor responsible for care, which was at the time, the General Practitioner.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 2 · response
Published 28 July 2017
Open published response
21 Dec2016
South Wales Central
Concerns raised1
1. Lack of comprehensive transfer handover of falls risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Bassett COOPER · 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

David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing 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
Lack of comprehensive transfer handover of falls risk
Wider context from the report
“1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls. For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered. ”
Source location
David Bassett COOPER · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Oct2016
Blackpool and the Fylde
Concerns raised1
1. Failure of the three-tier system to transfer key patient information quickly
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Barry 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

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

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 three-tier system to transfer key patient information quickly
Wider context from the report
“(4) Record keeping. /Information sharing. I found on hearing the evidence that records from both departments from 16.52 onwards are inaccurate, infrequently made, disjointed and are incomplete causing them to be unreliable and affected continuity of care. Also this caused staff at the inquest not to be able to fully recall their actions. There was a 3 stage system in place to ensure transfer of important information about Mr Thompson when he moved from the ED to the AMU. a) A SBAR document is completed by the transferring nurse who accompanies the patient. In this case the document does not state (despite there being provision on the form) who that person was or who the receiving nurse was. It does not identify Mr Thompson as a diabetic nor state he has not had his insulin. It erroneously states he is not on a sepsis pathway. b) There is a computerised tracking system providing for doctors in the ED to transfer key information about a patient to the doctors on the AMU. This then serves as a live reference point for staff on the ward. In this case the information refers to Mr Thompson having cellulitis only and makes no reference to his diabetes. This affected the prioritisation of Mr Thompson on the AMU particularly when it came to observations and testing needed and review by a doctor. c) The evidence from the ED matron was that either the named nurse or department co-ordinator should share key information by telephone with the ward prior to transfer. I concluded this did not occur as neither said they could remember doing so nor was there a record. The remainder of case notes which had come into existence whilst Mr Thompson was in the ED did go to the ward with him and referred to his diabetes and earlier assessments but I am concerned that the 3 tier system put in place to share key information quickly is not working. ”
Source location
Barry THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Feb2016
Manchester South
Concerns raised1
1. Failure to hand over patients’ individual needs from hospital to the ward
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Edith Kirkham · 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

Edith Kirkham fell at home on 13 August 2015, broke her hip, underwent surgery and was later moved to intermediate care, where she was not mobilised despite medical advice; she died some days later in North Manchester General Hospital. Concerns included unclear management arrangements, inadequate staffing and handover, failures to read or understand clinical instructions, lack of physiotherapy, and missing records relating to her stay.

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 hand over patients’ individual needs from hospital to the ward
Wider context from the report
“4. There was no apparent handover from the hospital to this ward, as to the individual needs of the patient, and the staff were therefore placed in an impossible position. ”
Source location
Edith Kirkham · Prevention of Future Deaths report
Page 1 · concerns
Open source report
20 Aug2015
North Wales (East and Central)
Concerns raised1
1. Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Andrew Selwyn Roberts · 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

Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.

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 provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Wider context from the report
“2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse. ”
Source location
Andrew Selwyn Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Jun2015
Brighton and Hove
Concerns raised1
1. Failure to communicate patients' care needs during ward transfers
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals Sussex NHS Foundation Trust
Stated actions 2
1. University Hospitals Sussex NHS Foundation Trust
  Integrate the fractured-neck-of-femur service at Princess Royal Hospital to provide continuity and avoid cross-site communication failures.
2. University Hospitals Sussex NHS Foundation Trust
  Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.
AI-generated summary

MR. ANTHONY GEERTS · 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

Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his 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
Failure to communicate patients' care needs during ward transfers
Wider context from the report
“Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”
Source location
MR. ANTHONY GEERTS · 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
Integrate the fractured-neck-of-femur service at Princess Royal Hospital to provide continuity and avoid cross-site communication failures.

Verbatim wording from the response
“May we start by expressing our sympathy on their sad loss to the family of Mr Geerts. Since he died, considerable changes have been implemented within this Trust specifically relating to the management of patients who have suffered a fractured neck of femur. Instead of routinely operating at the Royal Sussex County Hospital and then transferring the patients to the Princess Royal Hospital for rehabilitation, the whole service is now provided at the Princess Royal Hospital. This provides greater continuity for the patients, and indeed for the staff, and eliminates an opportunity for confusion or breakdown in communication between staff working in different places.”

Source location
2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 24 June 2015
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
Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.

Verbatim wording from the response
“g) educational sessions with ward nurses to explore the rationale for moving patients. This will include both emphasis on the need to provide adequate information to the clinical site manager if consideration is being given to moving a patient (especially late at night), and teaching on the documentation requirements (including completion of the transfer document), should it be unavoidable for a patient to be moved from one ward to another. This will help ensure that adequate information accompanies any patient who, for whatever reason, has to be moved from one ward to another.”

Source location
2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 24 June 2015
Open published response
15 Dec2014
Manchester South
Concerns raised1
1. Failure to pass relevant care information to successor staff
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sunrise Senior Living UK
Stated actions 1
1. Sunrise Senior Living UK
  Complete a full review of care documentation to improve continuity of information when care plans are updated.
AI-generated summary

RHYS TUDOR WILLIAMS · 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 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

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 pass relevant care information to successor staff
Wider context from the report
“6. There was an apparent failure by the staff (notably the managers who changed on a number of occasions) to pass relevant information to their successors, and the daughter of Dr Williams had to reiterate the same information several times. This led to a lack of confidence by the family of the deceased that his care needs were properly being made known to those having care of him. ”
Source location
RHYS TUDOR WILLIAMS · 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
Complete a full review of care documentation to improve continuity of information when care plans are updated.

Verbatim wording from the response
“We have undertaken a full review of our Care documentation. The revision proposes that when care plans are updated, all information will carry forward to the new plan. That includes all information obtained from all sources since the last update. This will remove the need for repeated communication of contact and background information when the new assessment is released. We had already commenced the process of contracting with an external archiving organisation which will enable a far more robust process of storing and retrieving residents’ historical documentation.”

Source location
2014-0558-Response-by-Sunrise-Senior-Living
Page 3 · response
Published 15 December 2014
Open published response
12 Nov2014
Preston and West Lancashire
Concerns raised1
1. Failure to routinely hand over ambulance-obtained ECG traces to A&E staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Anthony Ince · 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

David Anthony Ince was admitted to Royal Preston Hospital after collapsing at home and was discharged in the early hours. Shortly after returning home, he suffered a cardiac arrest and died despite readmission to hospital. Concerns were raised that an ECG recorded by ambulance staff was not documented in the A&E handover and that ECG traces were not routinely handed over to A&E staff.

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 routinely hand over ambulance-obtained ECG traces to A&E staff
Wider context from the report
“(1) In the course of the Inquest hearing, it became apparent that the NWAS electronic record referred to an ECG having been carried out on Mr Ince by the ambulance staff at 11.35pm, prior to his first admission to A&E. However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personnel on arrival at RPH, and no ECG trace was handed over or seen by A&E staff. (2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department. ”
Source location
David Anthony Ince · Prevention of Future Deaths report
Page 1 · concerns
Open source report
29 Aug2014
Inner North London
Concerns raised1
1. Failure to communicate pending physiotherapy assessment information
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Irshad ALI · 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

Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

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 pending physiotherapy assessment information
Wider context from the report
“4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place. The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family. The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go. Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete. ”
Source location
Irshad ALI · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Inadequate highlighting of particular patients' needs during handover

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised1

Failure to hand over urgent investigation needs to the responsible doctor

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of comprehensive transfer handover of falls risk

Concerns raised1

Failure of the three-tier system to transfer key patient information quickly

Concerns raised1

Failure to hand over patients’ individual needs from hospital to the ward

Concerns raised1

Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse

Concerns raised1

Failure to communicate patients' care needs during ward transfers

Linked response

Stated actions 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

Failure to pass relevant care information to successor staff

Linked response

Stated actions 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

Failure to routinely hand over ambulance-obtained ECG traces to A&E staff

Concerns raised1

Failure to communicate pending physiotherapy assessment information

Stated actions 1

Respondent positions 1

Stated actions 3

Respondent positions 3

Stated actions 2

Stated actions 1