Recurring concern

Unreliable safety review and escalation when clinical appointments are delayed or cancelled

First to latest report 10 May 2019 — 25 Mar 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes dedicated arrangements for identifying, clinically reviewing, reprioritising and escalating safety-relevant information or patient need when an assessment appointment is cancelled, postponed or delayed beyond the usual review timeframe.

What is not included
  • Excludes ordinary appointment scheduling, reminders or communication failures where no safety-relevant review or reprioritisation is required.
  • Excludes failures in clinical assessment after the appointment has occurred and the delayed-appointment safety process is no longer involved.
  • Excludes generic referral, staffing or documentation deficiencies unless they directly impair safety review or escalation after a cancelled or delayed appointment.
  • Excludes routine missed appointments or non-attendance where no concerning information, clinical urgency or need for escalation is identified.

Reports and published responses 3 reports

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

  1. Inner South London

    AI-generated summary

    Jacqueline Anne Cobain · 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

    Jacqueline Anne Cobain deliberately jumped in front of a moving train at Vauxhall London Underground station on 11 September 2021, suffering multiple injuries and dying at the scene. Her questionnaire responses to mental health services contained concerning responses, but the questionnaire was not reviewed until after her death because the system did not recognise that her appointment had been cancelled. The principal concern was the absence of a system or protocol to alert a clinician to review concerning responses when an assessment appointment was delayed by several days or weeks.

    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 system or protocol for timely clinical review and escalation of concerning questionnaire responses when assessment appointments are delayed

    Wider context from the report

    “1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire. 2. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses. 3. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death. 4. Changes have been made to the protocols around cancellation, and language has been added to the assessment template. 5. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case. ”

    Source location

    Jacqueline Anne Cobain · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    PHQ-9 responses are not diagnostic or predictive of suicidality and should not be used as a suicide risk assessment.

    Verbatim wording from the response

    “Mrs Cobain completed a number of short questionnaires. The questionnaire completed by Mrs Cobain which has caused some concern was the Patient Health Questionnaire-9. This is a measure used to give an indication of possible symptoms of depression experienced by an individual over the past two weeks. It is not a diagnostic tool nor is it a risk assessment. The questions are intended only to help inform and structure an in-person assessment. They are also used to provide a quantitative baseline against which progress in later treatment can be measured. Clinical research indicates that these types of measures have no predictive value as an assessment of suicidality and, indeed, recently published NICE guidance confirms that they must not be used in this way.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 2 · response
    Published 26 March 2024

    Open published response

  2. South Wales Central

    AI-generated summary

    Connor William DAVIES · 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

    Connor William Davies was found suspended by a ligature at a residential address on 13 April 2019 and died by hanging; the inquest recorded a verdict of suicide. The principal concern was that repeated cancellations of his mental health appointments did not trigger clinical review for urgent referral, creating a risk that patients in serious need could fall through the net.

    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 clinically review the urgency of patients when appointments are cancelled

    Wider context from the report

    “(1) Mr Davies was seen by a consultant psychiatrist in November 2018 and a follow up appointment made for January 2019. That appointment was cancelled and another made for March 2019. That too was cancelled and a further appointment made for June 2019 but before he could attend Mr Davies killed himself. ████████ who gave evidence confirmed that when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’ as may have been the case here. ████████ told me that he had endeavoured to put in place a system whereby this could be avoided but, to his knowledge, it is not yet operating. ”

    Source location

    Connor William DAVIES · 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

    Review appointment-cancellation processes to ensure urgent referral needs receive appropriate clinical input.

    Verbatim wording from the response

    “Synopsis of Concern: To review the existing processes that determine the appropriate priority for booking of appointments, to ensure allocation of clinics across the appropriate level of clinicians.”

    Source location

    2019-0412-Response-by-University-Health-Board
    Page 2 · response
    Published 29 December 2019

    Open published response

  3. Inner North London

    AI-generated summary

    Karanbir Singh CHEEMA · 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

    Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.

    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

    Delays in time-critical asthma and allergy review appointments

    Wider context from the report

    “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital. By the time of his death four months later he had still not been seen again. There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay. ”

    Source location

    Karanbir Singh CHEEMA · Prevention of Future Deaths report
    Page 4 · 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

    Require clinical review of patients for time-critical appointments before cancelling clinics and arrange an appropriate alternative appointment.

    Verbatim wording from the response

    “3. Re-booking cancelled clinics The relevant department has been advised that before a clinic list is cancelled (when there are patients already in the list), the clinician is given the list of patients of the clinic who then looks through to see if any of the appointments are “time critical” (as it was in Karanbir’s case) and then instructs the secretary or access centre to send out the appropriate alternate date for the next appointment.”

    Source location

    2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

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

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Data last updated 7 September 2026