Recurring concern

Unreliable tracking and completeness checking of faxed referrals and information

First to latest report 29 Jul 2016 — 14 May 2018

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 5

What this concern includes

Includes failures of the dedicated faxed-information transfer process, including logging sent or received faxes, confirming receipt, checking completeness and retaining an audit trail where those failures could result in missing or unrecognised safety-critical information.

What is not included

Excludes generic clinical or administrative record-keeping deficiencies not concerning faxed information transfer.
Excludes failures of scrutiny or assessment of information after a reliably completed fax transfer.
Excludes unrelated failures involving other communication channels, documents or systems unless the report explicitly ties them to the faxed-information transfer process.

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.

Avenue House Nursing and Care Home1

Care Quality Commission1

Department of Health and Social Care1

Kettering General Hospital1

Northamptonshire Healthcare NHS Foundation Trust1

Sussex Partnership NHS Foundation Trust1

Three Chequers Medical Practice1

Reports and published responses 3 reports

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

14 May2018
Northamptonshire
Concerns raised1
1. Failure to transmit and resubmit completed falls action plans through the required process
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Avenue House Nursing and Care Home
Stated actions 1
1. Avenue House Nursing and Care Home
  Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
Respondent positions 1
1. Avenue House Nursing and Care Home
  After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
  Redirects responsibility
AI-generated summary

Gladys Kathleen Rich · 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

Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

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 transmit and resubmit completed falls action plans through the required process
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
Source location
Gladys Kathleen Rich · 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
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.

Verbatim wording from the response
“Although we believe we followed normal and reasonable procedures in this case, in future to further mitigate against shortcomings of the Falls Team, we will contact them after sending them referrals and action plans. This will be done to ensure that the Falls Team have received them and to find out what action they intend to take. All contact will be recorded in our residents’ Care plans under the visiting professionals’ information section.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 1 · response
Published 8 July 2018
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 submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.

Verbatim wording from the response
“C) The management of the home completed the falls risk assessment and action plan and sent this by post, and not by the fax facility. There was a copy of this in the resident’s file for reference. There was no information in the resident’s file to say that the falls team hadn’t received this information. Mrs Rich had also been referred to the Falls Team prior to admission to Avenue House and again this was not followed up by the Falls Team. Once falls risk action plans are received by the falls team, they do not typically give the home even a rough estimate of how long it will be before it is followed up and the resident is seen. Therefore the care home simply has to wait for the Falls’ Team’s input.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 1 · response
Published 8 July 2018
Open published response
9 Feb2017
West Sussex
Concerns raised1
1. Failure to log and scrutinise faxes received by the Bognor EI team for missing pages and information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sussex Partnership NHS Foundation Trust
Stated actions 3
1. Sussex Partnership NHS Foundation Trust
  Display fax-handling guidance above EIP fax equipment.
2. Sussex Partnership NHS Foundation Trust
  Ensure 100% completion of Information Governance training among EIP staff.
3. Sussex Partnership NHS Foundation Trust
  Finalize, approve, disseminate and embed shared EIP referral standards covering information review, risk assessment, contact planning and recordkeeping.
AI-generated summary

Matthew Christopher 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

Matthew Christopher Roberts, a music student with a history of psychosis and a previous intentional insulin overdose, took a large overdose of insulin and prescribed psychotropic medication after returning to Sussex. He was admitted to intensive care in a coma with significant hypoxic brain damage and later died from a major haemorrhage at the tracheostomy site caused by acute arteritis of the innominate artery. Concerns included failures to log and scrutinise referral faxes, consider written clinical and risk information before assessing urgency, confirm the date of first contact, and formally review the death and seek relevant learning.

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 log and scrutinise faxes received by the Bognor EI team for missing pages and information
Wider context from the report
“(1) That there was no relevant policy, procedure or practice requiring faxes to the Bognor EI team be logged and scrutinised on receipt so that it might be noted if faxed pages were missing and potentially important information not received. ”
Source location
Matthew Christopher Roberts · 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
Display fax-handling guidance above EIP fax equipment.

Verbatim wording from the response
“All Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear guidance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year. Following Mr Roberts’ inquest, the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the key guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff.”

Source location
2017-0028-Response-by-Sussex-Partnership-NHS-Trust
Page 1 · response
Published 26 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
Ensure 100% completion of Information Governance training among EIP staff.

Verbatim wording from the response
“All Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear guidance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year. Following Mr Roberts’ inquest, the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the key guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff.”

Source location
2017-0028-Response-by-Sussex-Partnership-NHS-Trust
Page 1 · response
Published 26 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
Finalize, approve, disseminate and embed shared EIP referral standards covering information review, risk assessment, contact planning and recordkeeping.

Verbatim wording from the response
“The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this and have developed a clear set of shared standards for accepting referrals. Key elements of the standards are:”

Source location
2017-0028-Response-by-Sussex-Partnership-NHS-Trust
Page 2 · response
Published 26 February 2017
Open published response
29 Jul2016
Wiltshire and Swindon
Concerns raised2
1. Lack of an audit trail for faxed referrals to the Community Mental Health Team
2. Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
Linked responses

Department of Health and Social Care
The Endless Street Doctors’ Surgery
Stated actions 1
1. The Endless Street Doctors’ Surgery
  Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.
Respondent positions 2
1. Department of Health and Social Care
  The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.
  Existing arrangements considered sufficient
1. Department of Health and Social Care
  Responsibility for addressing the referral process rests locally with the surgery rather than centrally.
  Redirects responsibility
AI-generated summary

Miles Benedict Abel · 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 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.

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 an audit trail for faxed referrals to the Community Mental Health Team
Wider context from the report
“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
Source location
Miles Benedict Abel · Prevention of Future Deaths report
Page 1 · 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 consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
Wider context from the report
“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
Source location
Miles Benedict Abel · 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
Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.

Verbatim wording from the response
“Following the Critical Reporting Incident that followed the recent death of a patient, we have reviewed the system above and have instituted the new system – (Standard Operating Procedure - SOP enclosed):”

Source location
2016-0277-Response-by-The-Endless-Street-Doctors-Surgery
Page 1 · response
Published 29 July 2016
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 strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.

Verbatim wording from the response
“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location
2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016
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
Responsibility for addressing the referral process rests locally with the surgery rather than centrally.

Verbatim wording from the response
“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location
2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016
Open published response

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

Failure to transmit and resubmit completed falls action plans through the required process

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 log and scrutinise faxes received by the Bognor EI team for missing pages and information

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

Concerns raised2

Lack of an audit trail for faxed referrals to the Community Mental Health Team

Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals

Linked responses

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.2

Stated actions 1

Respondent positions 1

Stated actions 3

Stated actions 1

Respondent positions 2