Recurring concern

Unreliable care-planning processes

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First reported 1 Aug 2013•Latest report 2 Jun 2026

Definition

What this concern includes

Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.

Not included

  • Excludes standalone procedural instructions, treatment steps, extubation plans and immediate deterioration-management plans unless the source explicitly identifies them as part of the person's formal care plan.
  • Excludes organisational improvement plans, staffing plans and operational contingency plans.
  • Excludes discharge planning, risk assessment, family involvement or generic records when that separate control is the concern and formal care-plan reliability is not directly asserted.
Reports
120

Distinct published reports

Individual concerns
141

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
200

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14
Care Quality Commission9
Sussex Partnership NHS Foundation Trust9
Essex Partnership University NHS Foundation Trust7
NHS England7
Ministry of Justice5
Avon and Wiltshire Mental Health Partnership NHS Trust4
Barts Health NHS Trust4
Norfolk and Suffolk NHS Foundation Trust4
North East London NHS Foundation Trust4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Central and North West London NHS Foundation Trust3
Hc-One Limited3
HM Prison and Probation Service3
Office of the Chief Coroner3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. South Wales Central

    AI-generated summary

    Maurice ISAACS · 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

    Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.

    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 comprehensively assess and record falls risk and implement a clear care plan

    Wider context from the report

    “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward. His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls. ”

    Source location

    Maurice ISAACS · 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

    Commence and regularly review falls care plans for all patients identified as at risk.

    Verbatim wording from the response

    “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 2 · response
    Published 9 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.

    Verbatim wording from the response

    “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 2 · response
    Published 9 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain behaviour charts to identify triggers for falls and wandering behaviour.

    Verbatim wording from the response

    “All patients with known cognitive impairment have documentation completed by themselves or by a relative or carer in order to help healthcare staff learn about the patient as a person. We recognise that in the case of Mr I, regrettably, the ‘Reach Out To Me’ document had not been completed. All staff have been reminded of this and it will form part of regular documentation audits. Behaviour charts are maintained to identify any triggers for falls and wandering behaviour. Tools such as Intentional Rounding, which ensures that patients are reviewed every two hours in order to ensure that patients have a drink, are offered toileting in a timely manner are well embedded within all Directorates. Medication reviews are undertaken weekly by the medical team and Pharmacy colleagues to minimise medication interactions and use of sedative medication.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 2 · response
    Published 9 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete daily multidisciplinary Board Rounds providing a patient-centred holistic review.

    Verbatim wording from the response

    “Daily Board Rounds supported by a multi-disciplinary team approach are completed to provide a patient centred holistic review.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 2 · response
    Published 9 February 2017

    Open published response

  2. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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 draft falls prevention care plans after identified increased falls risk

    Wider context from the report

    “1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”

    Source location

    Margaret Emily TUCK · 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

    Implement falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.

    Verbatim wording from the response

    “1. The Hospital has undertaken a major piece of work to ensure vulnerable patients are identified and cared for, ensuring their risk of falling is minimised. A falls working group meets monthly, with each clinical area having to present their incidence of falls and work in progress around reduction of these incidents. On the AAU (representative of most clinical areas) all patients are assessed using the Trust falls assessment paperwork (which has been newly amalgamated into a nursing documentation admissions booklet), and any patient identified as a high risk, is then issued with a brightly coloured wrist band with the words ‘HIGH RISK OF FALLS’ printed on it. This signals to all staff, whether regular or agency, that this patient is at risk. All our high risk patients are now under within a bay that allows direct observation by nurses at the nurses’ station.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    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

    Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response

  3. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 make specific obstetric care plans for pregnancy and labour after bariatric surgery

    Wider context from the report

    “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians. ”

    Source location

    Rhi anne Anoushka Florence BARTON · 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

    Introduce and disseminate a guideline covering care from booking through delivery for pregnant patients who previously underwent bariatric surgery.

    Verbatim wording from the response

    “The Division (Womens Health and Paediatrics) have produced a Guideline For The Management Of Pregnant Women Who Have Previously Undergone Bariatric Surgery which details the care pathway for this group of patients from booking of the pregnancy through to delivery. The document was ratified by the Divisional Governance Group in December 2015 and widely publicised to all stakeholders within the Trust. A copy of this guideline is available on request.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 1 · response
    Published 1 June 2016

    Open published response

  4. Leicester City and South Leicestershire

    AI-generated summary

    Ahmedreza Fathi · 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

    Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

    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 robust, effective and event-responsive complex case planning

    Wider context from the report

    “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  5. Preston and West Lancashire

    AI-generated summary

    Dorothy Imsson · 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

    Dorothy Imsson died at Cleveleys Nursing Home on 9 August 2014 from a naturally occurring stroke caused by atrial fibrillation. Her death was contributed to by the absence of pressure care planning by qualified staff, resulting in severe skin ulceration, a shortening of life, and increased pain and suffering. Concerns also included the District Nursing Service's failure to develop an appropriate care plan and alleged failures to follow NMC guidance, record-keeping requirements, and NICE guidelines.

    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 develop appropriate care plans

    Wider context from the report

    “(1) No appropriate care plan was developed by the District Nursing Service. (2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping (3) The District Nursing Services are compromising patient care by not following NICE guidelines. ”

    Source location

    Dorothy Imsson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Norfolk

    AI-generated summary

    PAMELA JOYCE THURSTON · 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

    Pamela Joyce Thurston, a resident of Cedar Care Home with Alzheimer's dementia, choked on toast after being given food following an approximately 17-hour period without eating and without direct supervision. She developed bronchopneumonia and died in hospital two days later. The substantive concerns included her not being given breakfast, the lack of direct supervision while eating, and the response to the choking incident.

    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 update care plans following identified choking risks

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”

    Source location

    PAMELA JOYCE THURSTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Bedfordshire and Luton

    AI-generated summary

    Isla Peyton LORD · 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

    Isla Peyton LORD was born at Harlow Hospital on 4 November 2012 and suffered an immediate post-natal collapse after delivery, resulting in a hypoxic brain injury. She was transferred to Luton and Dunstable Hospital, where treatment was withdrawn following discussions with her parents, and she died on 8 November 2012. The principal concern was the lack of liaison between the hospitals about the delivery plan after possible heart anomalies were identified.

    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 coordinate an agreed delivery plan between tertiary and local hospitals

    Wider context from the report

    “1. During the course of the evidence it became apparent that once the possibility of heart anomalies was identified at University College Hospital in London (UCLH), there was no liaison between Princess Alexandra Hospital in Harlow and UCLH as to the plan for the delivery of the baby. It was simply agreed that UCLH were content for her to be delivered at the local hospital with a referral being made to Great Ormond Street Hospital after delivery. In order to prevent deaths in the future there needs to be a review of the system that exists between the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an Agreed Delivery Plan for both mother and baby. ”

    Source location

    Isla Peyton LORD · 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

    Amend the obstetric ultrasound policy to require consultants to obtain and clearly document agreed delivery and neonatal care plans.

    Verbatim wording from the response

    “1. The Standard Operating Policy for obstetric ultrasound scanning has been amended to include that consultants in charge of patients referred for second opinion in tertiary centres should request a detailed plan for delivery of the mother and care of the baby. The policy also requests the consultants to document the plan clearly in the patient’s hand held notes and hospital notes.”

    Source location

    I-lord-Response
    Page 1 · response
    Published 5 February 2016

    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

    Disseminate the amended policy by adding it to the Trust guidelines folder and notifying obstetric doctors.

    Verbatim wording from the response

    “2. The new policy has been added to the Trust guidelines folder accessible by all clinicians.”

    Source location

    I-lord-Response
    Page 1 · response
    Published 5 February 2016

    Open published response

  8. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · 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

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    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 complete, signed, dated and reviewed care plans

    Wider context from the report

    “2. Mrs Brown’s care plan was incomplete, unsigned, undated and never reviewed, despite Mrs Brown falling from her bed on 8th March 2015. ”

    Source location

    Elsie Marjorie Brown · 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

    Train remaining key personnel on required procedures and resident documentation, with systems to monitor, audit and review effectiveness.

    Verbatim wording from the response

    “The Company appointed an independent consultant in December 2015 to carry out an investigation into matters that had come to light during the course of the inquest. Part of this investigation looked into why this, and other corporate documentation was not used as part of Mrs Brown’s care plan. The Company has now taken appropriate disciplinary action and a large amount of work has been undertaken with remaining key personnel to ensure they understand the procedures and are conversant with appropriate documentation that should be used throughout a resident’s stay at one of our homes. There are also systems in place to ensure these are monitored, audited and reviewed for their effectiveness (see 2 below)”

    Source location

    Elsie-Brown-Response
    Page 1 · response
    Published 4 December 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

    Use a care plan matrix assigning responsibility for reviewing individual care plans and monitor staff compliance.

    Verbatim wording from the response

    “The Company has always had clear guidance for all staff on the compiling of care plan documentation in a timely manner. As part of our ongoing quality improvement plan we introduced a care plan matrix in October 2015 (attached), which outlines which staff are responsible for reviewing which individual care plans and this is monitored by the management team to ensure all staff are fulfilling their individual duties.”

    Source location

    Elsie-Brown-Response
    Page 2 · response
    Published 4 December 2015

    Open published response

  9. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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 establish referral and treatment plans with timescales

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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

    Improve the quality of assessment and treatment plans.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 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

    Review and implement AABIT standard operating procedures.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  10. Brighton and Hove

    AI-generated summary

    Mr Brian James SHILLINGLAW · 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

    The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.

    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 amend and dynamically update care plans and risk assessment documentation

    Wider context from the report

    “(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

    Source location

    Mr Brian James SHILLINGLAW · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to create care plans, risk assessments and other admission documentation

    Wider context from the report

    “(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

    Source location

    Mr Brian James SHILLINGLAW · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026