Recurring concern

Unreliable patient contact during urgent recall and follow-up

First to latest report 7 Mar 2018 — 11 Jan 2023

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 failures in urgent patient contact and recall processes, including maintaining usable contact details, attempting available contact routes, using accurate and understandable communications, contacting relevant care providers where needed to support recall, and making further direct attempts or escalating when the patient cannot be reached.

What is not included

Excludes routine appointment reminders and ordinary follow-up communication where no urgent recall, deterioration or safety concern is identified.
Excludes failures to provide treatment, assessment or emergency response after the patient has been successfully contacted.
Excludes generic GP communication, referral or record-transfer deficiencies where urgent patient recall or follow-up contact is not the unsafe condition.
Excludes failures involving product recalls, police missing-person responses or other non-patient recall processes.

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.

Aneurin Bevan University LHB1

Care Quality Commission1

Department of Health and Social Care1

General Medical Council1

Royal United Hospital1

St George's Hospital1

Reports and published responses 3 reports

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

11 Jan2023
Gwent
Concerns raised1
1. Failure to make adequate efforts to establish contact when a patient cannot be reached
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Aneurin Bevan University LHB
Stated actions 1
1. Aneurin Bevan University LHB
  Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.
AI-generated summary

Lucy Amanda Jones · 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

Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.

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 make adequate efforts to establish contact when a patient cannot be reached
Wider context from the report
“1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”
Source location
Lucy Amanda Jones · 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
Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.

Verbatim wording from the response
“With regard to the policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage, the Adult Mental Health and Specialist Services Directorate has developed a policy to guide clinicians in their next steps when a person does not attend”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 2023
Open published response
28 Jan2019
West London
Concerns raised1
1. Failure of the contact and recall process to communicate effectively with the patient or GP
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dennis Peter Alfred Warner · 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

Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.

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 the contact and recall process to communicate effectively with the patient or GP
Wider context from the report
“(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate. ”
Source location
Dennis Peter Alfred Warner · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Mar2018
Inner West London
Concerns raised1
1. Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

St George'S University Hospitals NHS Foundation Trust
Stated actions 1
1. St George'S University Hospitals NHS Foundation Trust
  Amend Appendix 1 guidance to require appropriate callback messages and alternative contact attempts in urgent or emergency situations while protecting patient confidentiality.
AI-generated summary

Ms Ivanika Olivari · 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

Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.

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 attempt patient contact through all available contact phone numbers in urgent and emergency situations
Wider context from the report
“2. That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations. ”
Source location
Ms Ivanika Olivari · 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
Amend Appendix 1 guidance to require appropriate callback messages and alternative contact attempts in urgent or emergency situations while protecting patient confidentiality.

Verbatim wording from the response
“However, in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix 1 relating to leaving telephone messages, as follows:”

Source location
2018-0073-Response-by-St-Georges-University-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2018
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 make adequate efforts to establish contact when a patient cannot be reached

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

Concerns raised1

Failure of the contact and recall process to communicate effectively with the patient or GP

Concerns raised1

Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations

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

Stated actions 1

Stated actions 1