Recurring concern

Unreliable inter-agency information sharing for coordinated care

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First reported 29 May 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the inter-agency care information-sharing system, including inadequate arrangements, communication channels, shared records or contact mechanisms when these prevent timely access to relevant care, needs or risk information between agencies.

Not included

  • Excludes information-sharing failures unrelated to coordination between agencies supporting a person.
  • Excludes failures confined to a single organisation's records, assessment, documentation or communication process unless the report directly links them to inter-agency information sharing.
  • Excludes generic staffing, confidentiality, policy or technology deficiencies that are not specifically tied to the unsafe inter-agency information-sharing condition.
  • Excludes hazards involving public access to harmful information or physical communication and rescue equipment.
Reports
212

Distinct published reports

Individual concerns
235

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
492

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 Care57
NHS England39
Ministry of Justice14
Home Office11
Greater Manchester Health and Social Care Partnership9
HM Prison and Probation Service8
NHS Greater Manchester Integrated Care Board8
Care Quality Commission7
Greater Manchester Mental Health NHS Foundation Trust7
Birmingham and Solihull Mental Health NHS Foundation Trust6
Metropolitan Police Service6
College of Policing5
Greater Manchester Police5
Midlands Partnership University NHS Foundation Trust5
Pennine Care NHS Foundation Trust5

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. East Sussex

    AI-generated summary

    Trevor Alan MONERVILLE · 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

    Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.

    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

    Inadequate communication about prisoners’ health conditions

    Wider context from the report

    “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing, between the prison staff and family, briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate. Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication. ”

    Source location

    Trevor Alan MONERVILLE · 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 Regional Multi Professional Complex Case Clinic escalation for the most complex patients.

    Verbatim wording from the response

    “Practice Plus Group operates an integrated healthcare model. Any patients pending transfer back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex Case Clinic (MPCCC) prior to transfer. This allows oversight of all departments within the integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, attended by all clinical leads, and any relevant staff involved in patient care. For individual cases prison partners may be invited to attend and a care plan created with a named coordinator allocated. Practice Plus Group has now implemented a further point of escalation to Regional MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, on occasion, representatives from NHS England.”

    Source location

    Response from Practice Plus Group
    Page 4 · response
    Published 19 January 2024

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    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

    Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.

    Verbatim wording from the response

    “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 19 January 2024

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    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

    Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.

    Verbatim wording from the response

    “As to lack of integration of various systems, this is not an issue that Practice Plus Group can resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned to use SystmOne. As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

    Source location

    Response from Practice Plus Group
    Page 4 · response
    Published 19 January 2024

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    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

    Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.

    Verbatim wording from the response

    “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 19 January 2024

    Open published response
  2. Surrey

    AI-generated summary

    Meghan Irene CHRISMAS · 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

    Meghan Irene CHRISMAS attempted suicide by hanging on 18 October 2021 and, after resuscitation, died two days later on 20 October 2021 from a hypoxic brain injury. The report raised concerns about the delayed handling and supervision of communications in the Hampshire Police Force Control Room and the absence of an adequate structure for sharing important clinical information between NHS and private healthcare providers.

    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

    Absence of effective arrangements for sharing important clinical information between private and public healthcare providers

    Wider context from the report

    “a. Passage of information between NHS and private healthcare providers. At a time where pressures on the NHS exist, particularly for mental health services, it is of concern that measures which could alleviate this pressure (where someone sources private care) do not exist. There is little or no policy, guidance or other effective arrangements to share important clinical information about patients between private and public healthcare sectors. ”

    Source location

    Meghan Irene CHRISMAS · 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

    Enhance patient-information sharing with commissioned VCSE and independent/private healthcare providers.

    Verbatim wording from the response

    “NHS England is currently working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent/private sector providers who are commissioned by NHS organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 March 2024

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    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 proof-of-concept work to expand Summary Care Record access across private hospitals and independent healthcare services.

    Verbatim wording from the response

    “The SCR Team at NHS England have done significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services as part of Proof of Concepts (PoCs), into settings where SCRs have previously been unavailable. e.g. private GP Services. This work will continue throughout 2024. Clearly, it is difficult to define precisely what is included within “private hospitals and privately funded healthcare services”. However, all “private hospitals and independent healthcare services” that have approached NHS England to date seeking access to SCR have either been onboarded into the existing proof of concepts or there have been discussions with the requesters regarding initial setup and their use for access to SCR.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

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    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

    Report proof-of-concept learning to the Expert Advisory Committee, including benefits and potential unintended consequences.

    Verbatim wording from the response

    “Learnings from these PoCs will be reported back to the Expert Advisory Committee to better understand any benefits realised but also any potential unintended consequences. The SCR Team will work with the Expert Advisory Committee to seek full rollout approval in this sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

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    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

    Work with the Expert Advisory Committee to seek approval for full private-sector rollout and consider its scope, exclusions, constraints, and caveats.

    Verbatim wording from the response

    “Learnings from these PoCs will be reported back to the Expert Advisory Committee to better understand any benefits realised but also any potential unintended consequences. The SCR Team will work with the Expert Advisory Committee to seek full rollout approval in this sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

    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

    Transfer Summary Care Record users from the legacy SCRa service to the National Care Records Service.

    Verbatim wording from the response

    “It is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base and the private sector PoCs. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work has accelerated during 2023 and is projected to conclude during Q2 2024.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

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    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

    Local Integrated Care Boards are responsible for delivering shared care records, developed according to local health and care needs and existing systems.

    Verbatim wording from the response

    “Responsibility for delivering shared care records sits with local Integrated Care Boards (ICB). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

    Open published response
  3. Surrey

    AI-generated summary

    Barbara Ann WOODMAN · 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

    Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

    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

    Inaccessibility of primary care records to secondary mental health services

    Wider context from the report

    “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████. The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. ”

    Source location

    Barbara Ann WOODMAN · 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

    Achieve national read-only interoperability between Shared Care Records across England.

    Verbatim wording from the response

    “There is now a target to achieve national interoperability (read only) between all Shared Care Records in England by March 2025. This project will ensure that any authorised health and care professional can have safe, secure and ready access to the person-based information they need to deliver high quality individual (direct) care.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 February 2024

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    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

    NHS England is best placed to address the absence of a unified record-keeping system across NHS providers.

    Verbatim wording from the response

    “In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.”

    Source location

    Surrey Council and Surrey NHS Joint Response
    Page 2 · response
    Published 23 February 2024

    Open published response
  4. Inner North London

    AI-generated summary

    Mohammed Zeeshan Akram (Zee) · 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

    Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

    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 prescribing GPs about medication non-adherence and stockpiling risks

    Wider context from the report

    “I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed. I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling. ”

    Source location

    Mohammed Zeeshan Akram (Zee) · 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

    Existing medication-review procedures and subsequent GP notification were considered sufficient; no additional GP communication was expected before the review.

    Verbatim wording from the response

    “This medication review by the prescribing clinician will automatically lead to the GP being notified when there are any changes to the client’s prescription or treatment plan, including whether the client has stopped taking the medication and any steps the service is taking to provide additional support. The expected standard is the GP would receive this correspondence via email within 48 hours of the medical review. In cases where a rapid medical review is arranged, the service will usually wait until the review before updating the GP, to ensure the GP is provided with the most up to date treatment plan.”

    Source location

    Response from Barnet Enfield and Haringey Mental Health NHS Trust
    Page 2 · response
    Published 29 November 2023

    Open published response
  5. Manchester South

    AI-generated summary

    Terence Davenport · 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

    Terence Davenport, who had severe dementia, was pushed by another resident at Kings Park Nursing Home on 23 May 2022, suffered a fractured neck of femur, and died at Tameside General Hospital on 24 September 2022 after declining following surgery. Concerns included his prolonged stay in an acute hospital because a suitable care placement was unavailable, and inadequate information sharing about the other resident’s aggressive behaviour, which meant risks to staff and residents were not understood.

    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 of safeguarding information sharing between local authorities, care homes and police

    Wider context from the report

    “2. The inquest was told that resident who pushed Mr Davenport was not suitable for placement at the care home where the incident happened. The care home where previous incidents had occurred was out of area. The inquest was told that lack of information sharing between two GM local authorities, the care homes involved and GMP meant that the safeguarding issue was not recognised. It was unclear if this was due to an effective information sharing protocol not existing between local authorities/care homes/GMP in Greater Manchester or it not being adhered to. However, the impact was that the risk of harm was not understood, and staff and residents were put at risk. ”

    Source location

    Terence Davenport · 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

    Present the case learning to Tameside care home managers and deliver a further session on discharge and transfers between community and acute settings.

    Verbatim wording from the response

    “Additionally learning from this report will be presented to Tameside Care Home Managers in December 2023; the learning will focus on sharing risk information across settings as well as completing robust pre-admission risk assessments. An additional face to face session will take place in February; this will be attended by ICFT Trust Colleagues with a focus on issues around discharge and transfer between community and acute settings.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 4 · response
    Published 30 October 2023

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    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

    Share learning through the Greater Manchester System Quality Group on robust information sharing when patients move across settings and localities.

    Verbatim wording from the response

    “3) Wider Learning via NHS Greater Manchester – learning will be shared via the GM System Quality Group around ensuring robust information being shared when patients are moving across settings and localities, this is particularly important currently due to current pressures on discharge.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 4 · response
    Published 30 October 2023

    Open published response
  6. Dorset

    AI-generated summary

    Marnie Emma Hill · 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

    Marnie Emma Hill was found collapsed and unresponsive on a bed at a property where she was temporarily residing on 15 May 2022. The report raised concerns that the lack of regulation of counselling could lead to future deaths, including because counsellors are not required to report risks or share records with healthcare professionals.

    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 requirements for counsellors to inform medical professionals or other appropriate support providers

    Wider context from the report

    “1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

    Source location

    Marnie Emma Hill · 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

    Training standards and practice requirements set by independent counselling organisations are outside Government oversight.

    Verbatim wording from the response

    “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 30 October 2023

    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

    Independent counselling organisations and their members are responsible for decisions about training standards and practice requirements.

    Verbatim wording from the response

    “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 30 October 2023

    Open published response
  7. Manchester South

    AI-generated summary

    Mark Anthony McKessy · 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

    Mark Anthony McKessy had learning disabilities and care needs and developed alcoholic liver disease following regular and prolonged alcohol use. He deteriorated after admission to Stepping Hill Hospital and died there on 18 February 2023. The principal concerns were poor communication and information sharing between agencies, lack of coordinated care, and insufficient recognition of how his health, social care and learning disability needs interacted, including the extent of his capacity.

    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

    Poor communication and information sharing between agencies

    Wider context from the report

    “The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to: 1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and 2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments ”

    Source location

    Mark Anthony McKessy · 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

    Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.

    Verbatim wording from the response

    “We continue to improve front line practice to ensure our frontline teams increase their knowledge and confidence in completing holistic assessments. To ensure management oversee individual assessments and reviews we are introducing peer discussions to strengthen social work practice. The social care and specialist learning disability health team are co-located to support a joined-up approach to interventions. This is further supported by managers across social care and health meeting on a weekly basis, using the forum to refer individuals for a multi-disciplinary and multi-agency approach.”

    Source location

    Response from Stockport Integrated Care Partnership
    Page 3 · response
    Published 30 October 2023

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    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 joint learning event involving agencies supporting people with learning disabilities to strengthen information sharing and practice.

    Verbatim wording from the response

    “There will be a joint learning event in January 2024 in relation to Mr McKessy’s life and death. All the agencies involved in supporting people with a learning disability in Stockport will be in attendance and agree a joint action plan to further strengthen information sharing and improvements to practice. We will also liaise with Mr McKessy’s family, if they wish to be involved, to share their experiences of the health and social care”

    Source location

    Response from Stockport Integrated Care Partnership
    Page 3 · response
    Published 30 October 2023

    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

    Agree a joint action plan following the learning event to improve information sharing and practice.

    Verbatim wording from the response

    “There will be a joint learning event in January 2024 in relation to Mr McKessy’s life and death. All the agencies involved in supporting people with a learning disability in Stockport will be in attendance and agree a joint action plan to further strengthen information sharing and improvements to practice. We will also liaise with Mr McKessy’s family, if they wish to be involved, to share their experiences of the health and social care”

    Source location

    Response from Stockport Integrated Care Partnership
    Page 3 · response
    Published 30 October 2023

    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

    Pennine Care NHS Foundation Trust cannot directly access patients’ full clinical histories through current systems.

    Verbatim wording from the response

    “All Stockport GPs use the Emis Clinical system, including our community and out of hours services. This means that community and out of hours services directly accessing individual patient clinical records. At the current time, Pennine Care NHS Foundation Trust cannot directly access a patient’s full clinical history. I can confirm that there is ongoing work within Greater Manchester to extend sharing of information across healthcare services.”

    Source location

    Response from Stockport Integrated Care Partnership
    Page 3 · response
    Published 30 October 2023

    Open published response
  8. Newcastle and North Tyneside

    AI-generated summary

    Brian David MORETON · 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

    Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

    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 communicate accurate clinically important information between clinicians and departments

    Wider context from the report

    “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

    Source location

    Brian David MORETON · 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

    Participate in a regular Inflammatory Bowel Disease multidisciplinary team meeting at Newcastle to improve communication and advice between the Trusts.

    Verbatim wording from the response

    “If specialist advice is required in relation to the management of colitis and any potential complications arising from this, even when the colitis is as a result of immunotherapy for the treatment of a melanoma, advice would be sought by the treating Gastroenterology team at North Cumbria, from the Gastroenterology team at Newcastle (as the tertiary centre), as the Gastroenterologists are the specialists dealing with colitis and any complications arising from this. This is why, following Mr Moreton's death, North Cumbria now take part in a regular Inflammatory Bowel Disease MDT at Newcastle, which as you heard at the inquest, has improved communication between the two Trusts and enables clinicians to more freely pick up the phone and seek advice.”

    Source location

    Response from DAC Beachcroft
    Page 1 · response
    Published 5 October 2023

    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

    Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

    Verbatim wording from the response

    “Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within various policies and SOPs, it would appear that this system has lost momentum within the Trust. SBAR is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to achieve this. Clinicians will be expected to utilise SBAR in any escalation of a clinical problem that requires attention, or to facilitate efficient handover, both internally and externally.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

    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

    Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.

    Verbatim wording from the response

    “The Trust now holds joint biweekly IBD multidisciplinary team meetings (MDTs) between the internal general surgery and gastroenterology teams. A triweekly joint specialist IBD MDT between the Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust has also been established since February 2023. An MDT, made up of a variety of specialists within an interest in IBD or gastroenterology, approach to the management of a patient’s IBD, is recommended to provide optimised and personalised care, based on available professional expertise, infrastructure and funding, and helps to prevent errors in the delivery of care and avoid related harm to patients. The timing of MDT meetings happen on the aforementioned frequencies to ensure decision-making is not delayed, however, such discussions largely relate to complex, chronic IBD patients.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

    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

    Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.

    Verbatim wording from the response

    “Acute or emergency care decisions cannot not be delayed for timetabled MDTs, but should happen separately between relevant specialists. The introduction of the MDTs has improved working relationships and communication between the teams and Trusts, to ensure early referrals for specialist input in the management of a patient’s care is sought, for patients who are acutely unwell and/or where urgent advice is required. Had the MDTs been in place during Mr Moreton’s admission, he likely would have been listed for discussion in both MDTs and professional relationships would have been established to seek earlier input from surgical colleagues and specialists in Newcastle.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

    Open published response
  9. Manchester South

    AI-generated summary

    Lauren Elizabeth Bridges · 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

    Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.

    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 of record-keeping systems to support direct transfer and sharing of clinical information

    Wider context from the report

    “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties. I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified. I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care. 1. The Priory deals with 42 NHS separate commissioning bodies. 2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible. 3. These bodies have varying processes and requests for communication. 4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’. ”

    Source location

    Lauren Elizabeth Bridges · 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

    Inadequate communication between mental health care providers and relevant parties

    Wider context from the report

    “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties. I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified. I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care. 1. The Priory deals with 42 NHS separate commissioning bodies. 2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible. 3. These bodies have varying processes and requests for communication. 4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’. ”

    Source location

    Lauren Elizabeth Bridges · 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 an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.

    Verbatim wording from the response

    “3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.”

    Source location

    Response from Dorset Healthcare University NHS Foundation Trust
    Page 2 · response
    Published 13 November 2023

    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

    Implement a live Microsoft Teams handover channel linked to electronic records for documenting bed-flow updates, discussions and decisions.

    Verbatim wording from the response

    “4. Clinical Site Managers now use a live Microsoft Teams channel for communicating updates between them on requirements around bed flow, which is linked to patient electronic records. This replaces previous paper handover records and ensures that there is documentation of bed flow discussions and decisions, for example, if there are moves of patients between wards in order to create bed capacity in a specific ward to facilitate an admission, that this is”

    Source location

    Response from Dorset Healthcare University NHS Foundation Trust
    Page 2 · response
    Published 13 November 2023

    Open published response
  10. Worcestershire

    AI-generated summary

    Anthony John Friend · 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

    Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.

    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 handovers between care agencies about care needs and safety concerns

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death ); 2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist; 3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.; 4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”. ”

    Source location

    Anthony John Friend · 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 communicate concerns about continued unsafe sling use in writing to care agencies

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · 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

    Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.

    Verbatim wording from the response

    “Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continuing to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.”

    Source location

    Response from Bluebird Care
    Page 3 · response
    Published 18 September 2023

    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

    Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.

    Verbatim wording from the response

    “From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.”

    Source location

    Response from Bluebird Care
    Page 4 · response
    Published 18 September 2023

    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 a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.

    Verbatim wording from the response

    “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 3 · response
    Published 18 September 2023

    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

    Implement and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.

    Verbatim wording from the response

    “As a Trust we recognise that more timely action was required about removal of older slings so we have in partnership with a range of professionals designed a focus-on-card around a step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a direct impact from this serious incident. This will act as a useful reminder document that staff will have access to when visiting patients in their homes and will be a vital part of new starter’s induction packs.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 2 · response
    Published 18 September 2023

    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 existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.

    Verbatim wording from the response

    “As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.”

    Source location

    Response from Bluebird Care
    Page 2 · response
    Published 18 September 2023

    Open published response
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Data last updated 7 September 2026