Recurring concern

Failure to reliably record safety information received from external organisations

First to latest report 24 Dec 2015 — 6 Feb 2026

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
5

What this concern includes

Includes failures of processes dedicated to acknowledging, recording or preserving safety-relevant referrals, reports, discussions or advice received from external organisations or third parties, including externally generated Datix referrals and information intended for clinicians taking over care.

What is not included
  • Excludes generic clinical-record deficiencies where the information was not received from an external organisation or third party.
  • Excludes failures of ordinary inter-agency information sharing where the material deficiency is transfer or access rather than recording information after receipt.
  • Excludes failures in investigation, learning or action after externally received information was reliably recorded.
  • Excludes generic incident-reporting failures concerning internally generated patient-safety incidents unless the assertion specifically concerns recording information received from an external organisation.

Reports and published responses 7 reports

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

  1. Devon, Plymouth and Torbay

    AI-generated summary

    Linda Brooks · 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

    Linda Brooks, a 78-year-old care-home resident with respiratory and other comorbidities, was admitted after a fall and later died at Torbay Hospital on 17 May 2022. The inquest identified concerns about oxygen being switched off for an unknown period before her death, and about failures to report, investigate, escalate, and record the incident and related Datix referrals.

    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 a process for recording Datix referrals made by other organisations

    Wider context from the report

    “4. There appeared to be no process for recording the fact that another organisation such as SWAST had made a Datix referral which would then have mitigated the fact that the SWAST Team failed to pass on their own DATIX to Torbay and South Devon NHS Trust. ”

    Source location

    Linda Brooks · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a process to receive external incident referrals, log them on DCIQ where needed, route them for investigation, and share outcomes with reporting organisations.

    Verbatim wording from the response

    “To ensure incidents raised by partner organisations (e.g., SWAST) are reliably captured and actioned, the Trust operates a defined process to receive external referrals, log them on DCIQ where needed, and route them for investigation.”

    Source location

    2026-0085 - Response from Torbay and South Devon NHS Trust
    Page 6 · response
    Published 13 February 2026

    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 the LfPSE-compliant reporting system to support cross-organisational routing of incidents to the relevant organisation.

    Verbatim wording from the response

    “In addition, the Trust’s incident reporting system is compliant with the national Learning from Patient Safety Events (LfPSE) service, supporting cross-organisational routing of incident reports where the incident occurred in another organisation.”

    Source location

    2026-0085 - Response from Torbay and South Devon NHS Trust
    Page 6 · response
    Published 13 February 2026

    Open published response

  2. North East Kent

    AI-generated summary

    Upali Meththanananda · 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

    Upali Meththanananda underwent coronary artery bypass surgery and was later admitted with a large left-sided pleural effusion. He died after a chest drain inserted on 20 October 2023 was followed by hypovolaemia, bleeding and cardiorespiratory arrest; concerns were raised about inadequate documentation of observations, procedures and discussions between clinicians.

    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 document discussions and advice from other organisations or third parties

    Wider context from the report

    “(1) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future. ”

    Source location

    Upali Meththanananda · 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 a communication plan highlighting accurate, timely clinical documentation, discharge documentation and appropriate use of copying and pasting.

    Verbatim wording from the response

    “○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.”

    Source location

    2025-0308 Response from East Kent Hospitals NHS Trust
    Page 2 · response
    Published 3 July 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

    Introduce the improved Electronic Discharge Notification for clearer clinical documentation.

    Verbatim wording from the response

    “○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.”

    Source location

    2025-0308 Response from East Kent Hospitals NHS Trust
    Page 2 · response
    Published 3 July 2025

    Open published response

  3. Newcastle upon Tyne and North Tyneside

    AI-generated summary

    David Michael O’Brien · 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 Michael O’Brien died at North Tyneside General Hospital after falling from his wheelchair, sustaining a hip fracture, and developing bronchopneumonia. Concerns included excessive wheelchair use despite advice that it was for mobility only, inadequate communication and record keeping between care providers, failure to undertake a risk assessment, and advice about the wheelchair not being followed.

    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 document and follow advice from other agencies

    Wider context from the report

    “7. The evidence that I heard suggests that Springfield Health Care have poor record keeping and poor communication between staff. It also suggests that as an agency, it is not aware of which agencies are responsible for providing assistance to its clients. Advice given by other agencies appears not to have been documented or followed. ”

    Source location

    David Michael O’Brien · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Manchester West

    AI-generated summary

    Frances Elizabeth Greenhalgh · 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

    Frances Elizabeth Greenhalgh died on 10 April 2017 after taking a substantial overdose of Mirtazapine and Dihydrocodeine, following a recent hospital admission after an overdose and discharge with a mental health care plan. The principal concern was that the GP surgery did not promptly record or act on the RAID Team’s faxed notification and treatment plan, so the plan was not available to the GP at the deceased’s appointment.

    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 record notifications from external healthcare professionals promptly and make them available in patient records and computer systems

    Wider context from the report

    “1. During the Inquest evidence was heard that:- i. On the 22nd March 2017 the Surgery received a letter by fax message from the RAID Team in relation to a plan of treatment for the deceased which included actions to be taken by the General Practitioner. On the 4th April 2017, 13 days following the notification, the General Practitioner had not put the RAID Team notification with the deceased’s medical records and there was no record of the notification on the computer systems at The Surgery. ii. ████████ who no longer works at The Surgery, was not aware of any systems at The Surgery in relation to the receipt of notifications from Healthcare Professionals or the systems in relation to the recording of notifications and information on a patient’s record so that the information is available to a General Practitioner on the next appointment with the patient. On the 4th April 2017 ████████ was unaware of the notification from the RAID Team and there was no evidence that the deceased had received any communication from the General Practitioner after the 22nd March 2017 in relation to the plan agreed with the RAID Team on that date. 2. I request the Senior Partner of The Surgery to conduct a review of the documented protocols and systems relating to the processing and recording of notifications received from Healthcare Professionals, particularly where the notification is received from a Healthcare Professional outside The Surgery. The review should consider the training of Healthcare Professionals, including Doctors, and check systems to ensure that any notifications are recorded on the patient notes and on any computerised system available to Healthcare Professionals within The Surgery without delay so that the notification and any plan of treatment are available to a Doctor or Healthcare Professional at the next appointment with the patient. Furthermore the notification should trigger contact with the patient, if appropriate, and in any event, if the agreed plan requires contact, to enable the patient to receive the benefit of treatment and care in accordance with the plan without delay. ”

    Source location

    Frances Elizabeth Greenhalgh · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Mid Kent and Medway

    AI-generated summary

    Natalie Gray · 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

    Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.

    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 record significant third-party information in Rio notes

    Wider context from the report

    “(4) Significant information from third parties was not recorded in the Rio notes when received or at all ”

    Source location

    Natalie Gray · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Peter Arthur Rowe · 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 Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.

    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 preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record

    Wider context from the report

    “2. The fact of the GPs referral letter stating an allergy to both penicillin and aspirin appears to have been transferred on to the Adult Inpatient Prescription and Administration record and then deleted, albeit it is not clear by whom and when. ”

    Source location

    Peter Arthur Rowe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Staffordshire South

    AI-generated summary

    Angela Catherine Brealey · 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

    Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.

    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 a defined process for acknowledging and recording information received from third parties

    Wider context from the report

    “(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided? ”

    Source location

    Angela Catherine Brealey · 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

    Implement a policy and process for receiving and storing third-party information in RiO, including uploading written communications and recording verbal communications.

    Verbatim wording from the response

    “The Trust now has a clear policy and process for receiving and storing third party information in Rio which is in line with national policy. Lengthy written communications are uploaded to RiO as sent, so are available to the care team and a note made in the progress notes to identify they have been stored and the location. Verbal communication is recorded in progress notes in line with policy.”

    Source location

    2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 24 December 2015

    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

    Third-party information cannot be acknowledged where doing so would breach Caldicott confidentiality principles.

    Verbatim wording from the response

    “The Trust may not respond to information from third parties as we adhere to Caldicott Principles in the management of all service user information. Where these principles would be breached the recipient of the information would not acknowledge, to the third party, that the service user was known to the service.”

    Source location

    2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
    Page 1 · response
    Published 24 December 2015

    Open published response

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

Back to top

Data last updated 7 September 2026