Recurring concern

Unsafe management of refusal of necessary care or protective action

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First reported 16 Dec 2013•Latest report 21 Aug 2025

Definition

What this concern includes

Includes capacity-sensitive assessment, persuasion, escalation and protective decision-making when refusal of necessary treatment, care or disclosure creates a serious safety risk.

Not included

Advance decisions or lawful treatment choices with no identified process failure
General mental-capacity assessment unrelated to a refusal
Non-clinical consent disputes

Reports: 13
Individual concerns: 16
Date range: 2013–2025
Stated actions: 25

Reports 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.

NHS England3

North East London NHS Foundation Trust2

Care Quality Commission1

Central and North West London NHS Foundation Trust1

Cornwall Partnership NHS Foundation Trust1

Daughter of the deceased1

Department of Health and Social Care1

General Medical Council1

General Pharmaceutical Council1

Hama Medical Centre1

King's College Hospital1

Mersey Care NHS Foundation Trust1

Ministry of Justice1

NHS Cornwall and the Isles of Scilly Integrated Care Board1

North London Mental Health Partnership1

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.

29 Jul2016
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to safely manage patients with apparent capacity who decline treatment or care despite deterioration
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Hold a Learning from Experience meeting with relevant clinical staff to consider developing a care pathway, engaging family and friends, and producing an action plan.
  Stated by Cornwall Partnership NHS Foundation TrustStated planned
AI-generated summary

Danny Sweet · 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

Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.

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 safely manage patients with apparent capacity who decline treatment or care despite deterioration
Wider context from the report
“Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the Law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends state their condition is deteriorating. I recognise this is a difficult issue. I wonder, however, whether in such situations, clinicians should record in the notes and records their concerns that patients have capacity and yet may go on to self-harm. Furthermore, I feel it may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. I recognise there will be an obvious need to respect the rules on confidentiality. ”
Source location
Danny Sweet · 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
Hold a Learning from Experience meeting with relevant clinical staff to consider developing a care pathway, engaging family and friends, and producing an action plan.

Verbatim wording from the response
“It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by ████████ Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway.”

Source location
2016-0275-Response-by-Cornwall-NHS-Trust
Page 2 · response
Published 29 July 2016
Open published response
2 Jun2016
Manchester West
Concerns raised1
1. Lack of guidance for managing refusal of physical health observations and escalating for medical assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Complete a full review of MEWS operational guidance addressing responses to refused physical observations.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated completed
2. Action
  Revise MEWS guidance to instruct staff how to assess and escalate care when patients refuse MEWS monitoring.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progress
3. Action
  Issue the ratified revised guidance to inpatient teams and provide necessary frontline staff support and training for rollout.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated planned
AI-generated summary

Clarice Beverley Hilton · 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

Clarice Beverley Hilton, who had depression and anxiety, was admitted to a psychiatric unit after refusing food, fluids and prescribed medication. She refused physical observations after the first evening, became unresponsive following a deterioration in her physical health, and died on 23 January 2016 after transfer to hospital. The principal concern was the absence of policy or guidance for monitoring and responding when psychiatric patients refuse physical observations and MEWS assessment.

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 guidance for managing refusal of physical health observations and escalating for medical assessment
Wider context from the report
“i. That there is no policy or guidance in place within the psychiatric units governed by 5 Boroughs Partnership NHS Foundation Trust as to what action to take when a patient is refusing to allow the nursing staff to undertake observations to establish the condition of their physical health. I therefore request that consideration be given to establishing a policy within the Trust for the monitoring of the physical health of patients within the psychiatric unit in circumstances where a patient refuses to allow the nursing staff to calculate their MEWS, which would provide guidance to the nursing staff as to what action should be taken in these circumstances and when it is appropriate for a referral to be made for a Doctor to assess whether a patient requires transfer to the Medical Assessment Unit for further assessment and treatment. ”
Source location
Clarice Beverley Hilton · 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
Complete a full review of MEWS operational guidance addressing responses to refused physical observations.

Verbatim wording from the response
“In response to your concern that there is no policy or guidance within our psychiatric units to inform staff of what actions to take when a patient is refusing to allow observations to establish the condition of their physical health, I can confirm the Trust have completed the following:”

Source location
2016-0207-Response-by-5-Borough-Partnership-NHS-Trust_Redacted
Page 1 · response
Published 2 June 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
Revise MEWS guidance to instruct staff how to assess and escalate care when patients refuse MEWS monitoring.

Verbatim wording from the response
“We have changed our MEWS guidance to contain instruction for staff on assessing those who refuse to engage with MEWS monitoring.”

Source location
2016-0207-Response-by-5-Borough-Partnership-NHS-Trust_Redacted
Page 1 · response
Published 2 June 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
Issue the ratified revised guidance to inpatient teams and provide necessary frontline staff support and training for rollout.

Verbatim wording from the response
“At present our revised guidance is in draft form, once this guidance is ratified this will be issued to all of our In-patient Teams and we will provide support and training to front line staff where necessary to ensure successful roll out.”

Source location
2016-0207-Response-by-5-Borough-Partnership-NHS-Trust_Redacted
Page 2 · response
Published 2 June 2016
Open published response
16 Dec2013
Nottinghamshire
Concerns raised1
1. Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Update and provide staff access to the Mental Capacity Act policy.
  Stated by HMC (Kimberley) Limited (trading as Hama Medical CentreStated completed
2. Action
  Provide a Mental Capacity Act summary on the shared drive for staff reference.
  Stated by HMC (Kimberley) Limited (trading as Hama Medical CentreStated completed
3. Action
  Discuss the Mental Capacity Act during medical meetings to update staff on its principles, purposes and best-interests requirements.
  Stated by HMC (Kimberley) Limited (trading as Hama Medical CentreStated completed
1. Action
  Continue staff Mental Capacity Act training through appropriate courses and e-learning.
  Stated by HMC (Kimberley) Limited (trading as Hama Medical CentreStated in progress
2. Action
  Conduct a full mental capacity assessment when patients refuse medical treatment or hospital admission, following the practice policy.
  Stated by HMC (Kimberley) Limited (trading as Hama Medical CentreStated planned
AI-generated summary

Cynthia Fretwell · 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

Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

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 fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Source location
Cynthia Fretwell · 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
Update and provide staff access to the Mental Capacity Act policy.

Verbatim wording from the response
“1. The Practice has updated its MENTAL CAPACITY ACT 2005 POLICY. This is saved on the ‘shared drive’ for all the staff to access it as necessary. See attached.”

Source location
2013-0366-Response-by-Hama-Medical-Centre
Page 1 · response
Published 16 December 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide a Mental Capacity Act summary on the shared drive for staff reference.

Verbatim wording from the response
“2. A summary of the Mental capacity Act 2005 is also saved on the ‘shared drive’ for more detailed reference.”

Source location
2013-0366-Response-by-Hama-Medical-Centre
Page 1 · response
Published 16 December 2013
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 the Mental Capacity Act during medical meetings to update staff on its principles, purposes and best-interests requirements.

Verbatim wording from the response
“4. We have discussed the Mental Capacity Act during our Medical Meetings so that we are all updated on it. Particular attention has been paid to sections relating to the Principles of the Act, Purposes of the Act and Best interests, as highlighted in the copy of summary of Mental Capacity Act attached.”

Source location
2013-0366-Response-by-Hama-Medical-Centre
Page 1 · response
Published 16 December 2013
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
Continue staff Mental Capacity Act training through appropriate courses and e-learning.

Verbatim wording from the response
“Capacity Act and PREVENT. This event addressed the principles and application of the Mental Capacity Act, amongst other issues. They will continue to keep themselves updated by attending appropriate future courses. ████████ will be attending such course in the very near future. The Practice staff have attended a course to learn about Mental capacity Act in 2009 and will update themselves with e-learning this subject on ‘blue stream academy’.”

Source location
2013-0366-Response-by-Hama-Medical-Centre
Page 3 · response
Published 16 December 2013
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
Conduct a full mental capacity assessment when patients refuse medical treatment or hospital admission, following the practice policy.

Verbatim wording from the response
“2. A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital will be made in accordance with the guidelines in the Practice’s mental capacity policy attached.”

Source location
2013-0366-Response-by-Hama-Medical-Centre
Page 3 · response
Published 16 December 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to safely manage patients with apparent capacity who decline treatment or care despite deterioration

Actions described in response 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

Lack of guidance for managing refusal of physical health observations and escalating for medical assessment

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

Concerns raised1

Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 1

Actions described in response 3

Actions described in response 5