Recurring concern

Failure to communicate clinically important information reliably between care services

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First reported 27 Sep 2013•Latest report 10 Jun 2026

Definition

What this concern includes

Includes failures of the cross-service clinical information communication process, including stale or unsupported guidance for emergency clinicians, omitted care decisions, inaccurate handovers and information not reaching involved services.

Not included

Excludes failures confined to a single clinician's knowledge or competence where no cross-service information communication issue is identified.
Excludes generic training, staffing, documentation or information-system deficiencies that are not specifically tied to communicating clinically important information between care services.
Excludes delays or failures in treatment, referral or emergency access where the material communication failure is not part of the concern.

Reports: 144
Individual concerns: 157
Date range: 2013–2026
Stated actions: 271

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care25

NHS England24

Essex Partnership University NHS Foundation Trust5

Greater Manchester Mental Health NHS Foundation Trust5

NHS Greater Manchester Integrated Care Board5

Pennine Care NHS Foundation Trust5

Care Quality Commission4

Manchester University NHS Foundation Trust4

Aneurin Bevan University LHB3

Birmingham and Solihull Mental Health NHS Foundation Trust3

Cheshire and Wirral Partnership NHS Foundation Trust3

Health Services Safety Investigations Body3

Mid and South Essex NHS Foundation Trust3

Midlands Partnership University NHS Foundation Trust3

North West Ambulance Service NHS Trust3

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.

10 Jun2026
Manchester South
Concerns raised1
1. Lack of a structured cross-team handover from ED to speciality departments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Judith Marsland · 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

Mrs. Marsland died in hospital on 14 November 2025 after a urinary infection progressed to sepsis, septic shock and multiorgan failure. The principal concerns were that abnormal blood results were not reviewed or escalated, she was discharged without antibiotics, and key action-plan measures for structured handover and named clinical responsibility had not been implemented.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a structured cross-team handover from ED to speciality departments
Wider context from the report
“4) ████████ evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians. ”
Source location
Judith Marsland · Prevention of Future Deaths report
Page 3 · concerns
Open source report
3 Jun2026
Nottingham and Nottinghamshire
Concerns raised1
1. Delays or failures in delivery of ED discharge summaries
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David MARRIOTT · 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

David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries 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
Delays or failures in delivery of ED discharge summaries
Wider context from the report
“3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such. I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning. I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient. The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified? ”
Source location
David MARRIOTT · Prevention of Future Deaths report
Page 4 · concerns
Open source report
21 Apr2026
Gateshead and South Tyneside
Concerns raised1
1. Failure to clearly communicate treatment plans and required actions in consultant correspondence
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Produce national guidance on clear, concise, structured outpatient clinic letters and required primary-care actions.
  Stated by NHS EnglandStated completed
2. Action
  Develop the Red Tape Challenge to improve primary-secondary care communication, interface working, prescribing, records access, interoperability, and process standardisation.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  Implementation of measures improving primary-secondary care communication and prescribing is driven by integrated care boards, with national oversight.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Theresa Lydon · 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

Theresa Lydon had severe ulcerative colitis and was admitted to hospital on four occasions before her death following complications of surgery, including an intra-abdominal haemorrhage. The report identifies concerns about delayed prescribing, unclear communication of treatment plans, inadequate access to medical records between NHS Trusts, and the absence of repeated blood tests that contributed to her death.

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 clearly communicate treatment plans and required actions in consultant correspondence
Wider context from the report
“(1) During the course of the inquest it was established Mrs Lydon was diagnosed with a condition and treatment was prescribed in the form of a repeat prescription drug in May 2021. The diagnosing consultant set out the treatment plan in a letter to her GP and the format of the letter was such it was difficult for the receiving GP to see what actions were required by him. This is compounded when paper correspondence is routinely scanned and emailed by administrators and the GP is 'drawn' to certain sections of the document by the administrators. It was remarked in evidence by the GP that all consultants seem to format their correspondence differently and there is no uniform format so a GP can see clearly at the outset what the treatment plan is and what action needs to be taken. Evidence from the Hospital Trust in question stated they had changed the format of this type of correspondence to make it easier to identify the actions to be taken. In Mrs Lydon's case, the drug she was prescribed in May 2021 was not identified from the correspondence and was supplied to her in June 2022 when the situation was discovered. Whilst a remedy has been implemented locally I have a concern that nationally there is a risk of future deaths if important correspondence contained treatment plans is not clearly communicated to those responsible for implementing them. ”
Source location
Theresa Lydon · 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
Produce national guidance on clear, concise, structured outpatient clinic letters and required primary-care actions.

Verbatim wording from the response
“As that is not yet universal, nationally, the Getting it Right First Time (GIRFT) Team produced a Clinically Led Speciality Outpatient Guide document in July 2023 highlighting the importance of clear, concise clinic letters and offering guidance on the best ways to do this. This states that outpatient clinic letters have at least three different audiences, each of which will have different requirements for what they need to be able to take from the contents. In view of this, clinic letters must be clear, concise,”

Source location
Response from NHS England
Page 1 · response
Published 19 June 2026
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
Develop the Red Tape Challenge to improve primary-secondary care communication, interface working, prescribing, records access, interoperability, and process standardisation.

Verbatim wording from the response
“An initiative called the ‘Red Tape Challenge’ was developed to improve the interface between primary and secondary care, such as how referrals are made and managed, patient discharge and how different parts of the health service communicate with each other. The Red Tape Challenge led to 10 recommendations, which were cascaded through Regional Medical Directors. The focus of the Red Tape Challenge is on reducing unnecessary bureaucracy, improving communication and understanding, strengthening culture and interface working between primary and secondary care, improving digital and estates infrastructure, streamlining healthcare delivery, enhancing patient experience, and freeing up clinical time. Those especially relating to this case include:”

Source location
Response from NHS England
Page 6 · response
Published 19 June 2026
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
Implementation of measures improving primary-secondary care communication and prescribing is driven by integrated care boards, with national oversight.

Verbatim wording from the response
“An initiative called the ‘Red Tape Challenge’ was developed to improve the interface between primary and secondary care, such as how referrals are made and managed, patient discharge and how different parts of the health service communicate with each other. The Red Tape Challenge led to 10 recommendations, which were cascaded through Regional Medical Directors. The focus of the Red Tape Challenge is on reducing unnecessary bureaucracy, improving communication and understanding, strengthening culture and interface working between primary and secondary care, improving digital and estates infrastructure, streamlining healthcare delivery, enhancing patient experience, and freeing up clinical time. Those especially relating to this case include:”

Source location
Response from NHS England
Page 6 · response
Published 19 June 2026
Open published response
26 Mar2026
West Sussex, Brighton and Hove
Concerns raised2
1. Lack of an easily recognised national designator for significant wider and historical health and drug-misuse risks
2. Fragmented sharing and updating of health and drug-misuse information across providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Work with NHS England and sector partners to overcome barriers to data sharing between services.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Strengthen clinical leadership, multiagency working and information sharing through children and young people’s mental health reforms.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Reduce the longest waits for specialist mental health services.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Accelerate rollout of Mental Health Support Teams across England toward full national coverage.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Alex Ganski · 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

Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

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 easily recognised national designator for significant wider and historical health and drug-misuse risks
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · 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
Fragmented sharing and updating of health and drug-misuse information across providers
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · 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
Work with NHS England and sector partners to overcome barriers to data sharing between services.

Verbatim wording from the response
“Regarding your concerns raised in relation to sharing information and data between services and clinicians, the delivery framework also states that all service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need. This is also in line with the NICE guidance recommendations on information sharing, 1.4.6 and 1.4.7. Work is ongoing alongside NHSE and sector partners to overcome barriers to data sharing between services.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Strengthen clinical leadership, multiagency working and information sharing through children and young people’s mental health reforms.

Verbatim wording from the response
“Through our wider children and young people’s mental health reforms, we are working to strengthen clear clinical leadership and oversight, multiagency working, and information sharing, so that no child falls through gaps between services.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Reduce the longest waits for specialist mental health services.

Verbatim wording from the response
“Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Accelerate rollout of Mental Health Support Teams across England toward full national coverage.

Verbatim wording from the response
“Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
Open published response
16 Jan2026
Coventry
Concerns raised1
1. Failure to pass important risk information to the Home Treatment Team
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.
  Stated by NHS Coventry and Warwickshire NHS TrustStated in progress
2. Action
  Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.
  Stated by NHS Coventry and Warwickshire NHS TrustStated planned
AI-generated summary

Wayne Pierce Walton · 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

Wayne Pierce Walton was discharged from the Caludon Centre on 21 June 2024 after taking an overdose with the intention of ending his life. He failed to engage consistently with the Home Treatment Team and died by asphyxiation on 29 June 2024. Concerns included inadequate completion and transfer of risk assessment and safety plan information, and a lack of guidance on potential conflicts of interest involving staff who recognised a patient outside the circumstances covered by an existing policy.

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 pass important risk information to the Home Treatment Team
Wider context from the report
“(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”
Source location
Wayne Pierce Walton · 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
Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.

Verbatim wording from the response
“Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystemOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all.”

Source location
2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 1 · response
Published 21 January 2026
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
Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.

Verbatim wording from the response
“Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis.”

Source location
2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026
Open published response
9 Dec2025
Derby and Derbyshire
Concerns raised2
1. Lack of shared policies, guidance and understanding about information relevant for sharing between services
2. Failure to escalate and share increasing contact with health visitors with perinatal mental health services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.
  Stated by Derbyshire Community Health Services NHS Foundation TrustStated completed
2. Action
  Develop and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.
  Stated by Derbyshire Community Health Services NHS Foundation TrustStated planned
3. Action
  Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.
  Stated by Derbyshire Community Health Services NHS Foundation TrustStated in progress
1. Action
  Add contextual-information-sharing guidance to the electronic referral document for professionals.
  Stated by The TrustStated completed
2. Action
  Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
  Stated by The TrustStated planned
3. Action
  Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
  Stated by NHS EnglandStated planned
4. Action
  Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
  Stated by NHS Derby and Derbyshire Integrated Care BoardStated planned
5. Action
  Publish perinatal mental health care pathway guidance and provide supporting e-learning resources for healthcare staff.
  Stated by NHS EnglandStated completed
Respondent positions 2
1. Position
  The Practice does not consider a policy or guidance on relevant information sharing capable of assisting with this concern.
  Stated by Sett Valley Medical CentreNo action considered necessary
1. Position
  Continuing to share only clinically relevant contacts is considered safer and sufficient; emailing every consultation would burden the perinatal mental health team.
  Stated by Sett Valley Medical CentreExisting arrangements considered sufficient
AI-generated summary

Hannah Louise Booth · 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

Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.

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 shared policies, guidance and understanding about information relevant for sharing between services
Wider context from the report
“This inquest has exposed important issues with information sharing between services and also within services. Those issues are: • Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record. • A lack of a shared understanding of what is relevant information and needs to be made available to other services. • Relevant notes being made in records of baby and not repeated in notes of the mum. Further detail: 1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact. 2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services. 3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when. 4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period. ”
Source location
Hannah Louise Booth · Prevention of Future Deaths report
Page 3 · 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 escalate and share increasing contact with health visitors with perinatal mental health services
Wider context from the report
“This inquest has exposed important issues with information sharing between services and also within services. Those issues are: • Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record. • A lack of a shared understanding of what is relevant information and needs to be made available to other services. • Relevant notes being made in records of baby and not repeated in notes of the mum. Further detail: 1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact. 2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services. 3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when. 4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period. ”
Source location
Hannah Louise Booth · 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
Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.

Verbatim wording from the response
“During this meeting, it was agreed that the Perinatal Mental Health Service should be utilised by the Health Visiting Service as an advice and consultation resource, in addition to the existing formal referral pathways. Health Visitors are able to contact the Perinatal Mental Health Service advice line to discuss concerns, seek professional advice, or share relevant information without the need to submit a formal referral.”

Source location
Response from Derbyshire Community Health Service NHS Foundation Trust
Page 3 · response
Published 15 December 2025
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
Develop and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.

Verbatim wording from the response
“To support clarity and consistency in practice, the Perinatal Mental Health Service has agreed to develop an infographic for Health Visiting staff. This will provide clear, accessible guidance on:”

Source location
Response from Derbyshire Community Health Service NHS Foundation Trust
Page 3 · response
Published 15 December 2025
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
Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.

Verbatim wording from the response
“As a result of this discussion, the Health Visiting Service is in the process of updating its Standard Operating Procedures to reflect the agreed approach to information sharing and the use of the Perinatal Mental Health Service advice line. This update will provide clear, consistent guidance to staff and reinforce expectations regarding early consultation and sharing of relevant information.”

Source location
Response from Derbyshire Community Health Service NHS Foundation Trust
Page 4 · response
Published 15 December 2025
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
Add contextual-information-sharing guidance to the electronic referral document for professionals.

Verbatim wording from the response
“Information leaflet to GP’s on referral The Perinatal CMHT has drafted an information leaflet for GPs setting out that this Trust and the GP practice use different electronic patient record systems, highlighting the impact of this and detailing risk mitigation. This leaflet will be sent to GPs on receipt of a referral from them if they do not have the same electronic patient record. An additional page has been added to the e-referral document for professionals regarding the sharing of contextual information around the patient. A patient will also be informed that their GP is not on the same electronic patient record so that they too are aware that information sharing is not automatic at the time of their appointment.”

Source location
Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.

Verbatim wording from the response
“Working alongside DCHS Further, and in addition, the Trust is currently discussing with Derbyshire Community Health Services NHS FT (‘DCHS’) the development of Guidance regarding when DCHS’ health visitors will cross reference the medical notes for baby and mum.”

Source location
Response from Derbyshire Healthcare NHS Foundation Trust
Page 2 · response
Published 15 December 2025
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
Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.

Verbatim wording from the response
“Following this case, NHS England via the regional Perinatal Mental Health networks will encourage specialist perinatal mental health teams to include record keeping as a component of their training to the wider pathway, to help support staff to understand their experiences for documenting assessments, risks, red flags, information sharing and consent.”

Source location
Response from NHS England
Page 3 · response
Published 15 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.

Verbatim wording from the response
“DDICB is committed to ensuring that providers understand their obligations to share information between providers, where that information relates to the delivery of patient care. We note the coronial concern around the lack of policy or guidance relating to the recording of information potentially relevant to both mother and baby; and guidance relating to information sharing between healthcare providers in the case of a pattern of more frequent access to services.”

Source location
Response from Nottingham and Nottinghamshire Integrated Care Board
Page 2 · response
Published 15 December 2025
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
Publish perinatal mental health care pathway guidance and provide supporting e-learning resources for healthcare staff.

Verbatim wording from the response
“The NHS has expanded specialist perinatal mental health support and access has more than doubled (113%) from 31,163 patients in March 2020 to 66,468 in October 2025. NHS England previously published guidance on perinatal mental health care pathways in May 2018, to support all healthcare professionals working across the wider perinatal mental health pathway in identifying cases requiring specialist input. This is supported by e-learning resources for all staff, including modules for health visitors and a broader perinatal mental health resource covering risks to parents.”

Source location
Response from NHS England
Page 2 · response
Published 15 December 2025
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 Practice does not consider a policy or guidance on relevant information sharing capable of assisting with this concern.

Verbatim wording from the response
“her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.”

Source location
Response from Sett Valley Medical centre
Page 4 · response
Published 15 December 2025
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
Continuing to share only clinically relevant contacts is considered safer and sufficient; emailing every consultation would burden the perinatal mental health team.

Verbatim wording from the response
“With regards to sharing ongoing information with the perinatal mental health team it was discussed whether clinicians should request for the secretarial team to email any consultations relating to mental health (not just a deteriorating condition) and the perinatal mental health team can decide whether this is relevant to the care they are providing to the patient. However, it was felt that emailing every consultation to the perinatal team would put an unsafe burden on the perinatal team and we as a Practice consider that it is better and safer for us to continue with our normal practice of sharing only relevant contacts if we feel it is clinically indicated. This is consistent with the hundreds of other specialities/patient groups that we consult with.”

Source location
Response from Sett Valley Medical centre
Page 2 · response
Published 15 December 2025
Open published response
12 Nov2025
Inner West London
Concerns raised1
1. Lack of a system for direct contact between the transplant team and local on-call nephrology team to exchange clinically relevant patient information
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a revised transplant-offer pathway requiring base-hospital nephrology contact, recent blood-test review, communication checkpoints, and regular audit.
  Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completed
2. Action
  Share electronic patient-record access between St George’s, Epsom, and St Helier to support transplant information transfer.
  Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completed
Respondent positions 1
1. Position
  Shared electronic patient-record access cannot be extended to Brighton, so the revised information-handover pathway must be used instead.
  Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupUnable to act
AI-generated summary

Mr Barry Clive Loxston · 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

Mr Barry Clive Loxston died at St George’s Hospital on 30 July 2023 after complications following renal transplant surgery, including electrolyte imbalance and delayed graft function. The report identifies concerns about failures to recognise his unfitness for surgery, inadequate patient handling, unsupervised medication administration, insufficient investigation, incomplete review of blood tests, and gaps in systems for assessing transplant-list suitability and communication between nephrology teams.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system for direct contact between the transplant team and local on-call nephrology team to exchange clinically relevant patient information
Wider context from the report
“6. That there is no system recommending direct contact with the local on call nephrology team by the transplant team to check whether there are clinically relevant matters in relation to the patient and their suitability for transplant that the local team are aware of and the transplant team are not, such as active other chronic illness or abnormal test results. ”
Source location
Mr Barry Clive Loxston · 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
Implement a revised transplant-offer pathway requiring base-hospital nephrology contact, recent blood-test review, communication checkpoints, and regular audit.

Verbatim wording from the response
“Matter 6: There is a revised pathway that outlines the actions required when a kidney offer is received for transplant. This states that contact should be made with various teams, including the nephrologist at the base hospital. We have added multiple points along the pathway to ensure that communications are made appropriately and built in regular audit to provide assurance of the effectiveness of these processes (see appendix).”

Source location
Response from St George's University Hospitals
Page 5 · response
Published 14 November 2025
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
Share electronic patient-record access between St George’s, Epsom, and St Helier to support transplant information transfer.

Verbatim wording from the response
“In addition, now that the same electronic patient record system at St George’s has been adopted at Epsom and St Helier, access to patient records will be shared across the sites. This cannot be rolled out for Brighton, however the revised pathway acts to ensure robust handover of information.”

Source location
Response from St George's University Hospitals
Page 5 · response
Published 14 November 2025
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
Shared electronic patient-record access cannot be extended to Brighton, so the revised information-handover pathway must be used instead.

Verbatim wording from the response
“Matter 6: There is a revised pathway that outlines the actions required when a kidney offer is received for transplant. This states that contact should be made with various teams, including the nephrologist at the base hospital. We have added multiple points along the pathway to ensure that communications are made appropriately and built in regular audit to provide assurance of the effectiveness of these processes (see appendix).”

Source location
Response from St George's University Hospitals
Page 5 · response
Published 14 November 2025
Open published response
7 Nov2025
Suffolk
Concerns raised1
1. Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
  Stated by Suffolk ConstabularyStated planned
2. Action
  Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
  Stated by Suffolk ConstabularyStated in progress
3. Action
  Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
  Stated by Suffolk County CouncilStated in progress
Respondent positions 5
1. Position
  Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
  Stated by Suffolk ConstabularyExisting arrangements considered sufficient
1. Position
  NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
  Stated by Suffolk ConstabularyRedirects responsibility
2. Position
  A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
  Stated by Suffolk ConstabularyUnable to act
3. Position
  Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
  Stated by Suffolk County CouncilRedirects responsibility
4. Position
  SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
  Stated by Suffolk County CouncilOutside remit
AI-generated summary

Anthony Robert CARD · 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 Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
Wider context from the report
“Outside of situations where section 42 of the Care Act 2014 applies, there appears to be no mechanism available to enable front-line police officers who wish, of their own volition and with the subject's consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers, whom may be the right person or agencies to provide support in the medium term. The information that an individual has, for example, been reported as presenting in such a way that police have had to consider detaining them under section 136 of the Mental Health Act 1983 could be important risk information that would assist medical or mental health care providers. Not having this risk information available in future assessments may adversely affect decision-making - e.g. not having this information available could contribute to a decision not to admit compulsorily the patient for mental health care if they were to present again in, say, one week from the police interaction. If such risk information is not received by treating medical or mental health care providers, there may be omission to offer vital further mental health support. ”
Source location
Anthony Robert CARD · 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
Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.

Verbatim wording from the response
“Suffolk Constabulary commit to:”

Source location
Response from Suffolk Constabulary
Page 3 · response
Published 12 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.

Verbatim wording from the response
“Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.”

Source location
Response from Suffolk Constabulary
Page 4 · response
Published 12 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.

Verbatim wording from the response
“SCC will continue to co-operate with other partner agencies and share relevant information in accordance with applicable information-sharing arrangements, to support timely access to clinically led crisis assessment where suicide risk is identified”

Source location
Response from Suffolk County Council
Page 3 · response
Published 12 February 2026
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
Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.

Verbatim wording from the response
“Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.”

Source location
Response from Suffolk Constabulary
Page 4 · response
Published 12 February 2026
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
NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.

Verbatim wording from the response
“Your Regulation 28 Report is addressed to both Suffolk Constabulary and Suffolk County Council (Adult Social Care), however is not addressed to Norfolk and Suffolk NHS Foundation Trust (“NSFT”). It is important to note that NSFT hold both the statutory and operational responsibility for adult mental health care across Suffolk.”

Source location
Response from Suffolk Constabulary
Page 2 · response
Published 12 February 2026
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
A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.

Verbatim wording from the response
“A new MASH referral pathway for adult mental health concerns is not, in our respectful submission, viable. Creating a pathway for Medium-risk adult mental health referrals falling short of section 42 of the Mental Health Act would generate an estimated 500 additional referrals per month, creating substantial operational impact across the police and Adult Social Care. This would require a structural redesign of MASH which, in our view, would not lead to improved outcomes due to adult mental health sitting wholly within the remit of NSFT as opposed to within MASH. As addressed below, NHS 111 Option 2 already exists as the appropriate clinical route for sharing concerns falling outside of the statutory framework.”

Source location
Response from Suffolk Constabulary
Page 2 · response
Published 12 February 2026
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
Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.

Verbatim wording from the response
“The responsibility for adult mental health provision and clinical pathways as identified by the report rests predominantly with NHS commissioners and NHS mental health providers (this is without prejudice to SCC’s distinct statutory responsibilities in respect of mental health social care, including Care Act functions and, where applicable, joint aftercare duties under the Mental Health Act).”

Source location
Response from Suffolk County Council
Page 1 · response
Published 12 February 2026
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
SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.

Verbatim wording from the response
“Where information relates solely to adult mental health concerns and does not meet statutory adult safeguarding criteria and/or does not otherwise engage adult social care functions, SCC is not the appropriate recipient for clinical triage or onward clinical referral into adult mental health pathways. Where a contact nonetheless indicates an appearance of care and support needs, SCC will consider whether Care Act assessment duties are engaged.”

Source location
Response from Suffolk County Council
Page 2 · response
Published 12 February 2026
Open published response
31 Oct2025
Liverpool and the Wirral
Concerns raised1
1. Failure to accurately identify the care setting and available clinical staff in requests for care
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Amend the home’s NHS email address to identify Riversdale as a care home.
  Stated by Riversdale (Northwest) LimitedStated completed
2. Action
  Notify external professionals that Riversdale is a residential care home without nurses on site.
  Stated by Riversdale (Northwest) LimitedStated completed
AI-generated summary

Gloria SIMON · 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

Gloria Simon moved into a care home for respite care and died there from natural causes on 20 September 2025 after her health deteriorated. Concerns included missed opportunities for timely clinical assistance, a GP misunderstanding the care home setting and oxygen saturation reading, and possible insufficient training of non-clinical staff in seeking help and taking and responding to basic observations.

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 accurately identify the care setting and available clinical staff in requests for care
Wider context from the report
“1. The email sent to the GP practice with the ‘Request for Care’ form noted the sender’s email address to be ████████ (RIVERSDALE NURSING HOME, WIRRAL). On the form itself, the box in which the sender was asked to identify the staff involved in the case was completed with the words ‘Riversdale Nursing Home’, which was its name before it changed from a nursing home to a care home in 2023. The GP to whom the request was passed for action told the court that he believed that the Gloria Simon was resident in a nursing home setting, and that he would have acted differently (by making a visit to see her in person) if he had known that it was in fact a care home setting, with no clinically qualified staff members on site. The court is concerned that this preventable misunderstanding contributed to a vulnerable elderly resident being left without a face-to-face clinical assessment (which would have been likely to result in a different approach to care and management) and would like to know what measures are being taken to address this. ”
Source location
Gloria SIMON · 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
Amend the home’s NHS email address to identify Riversdale as a care home.

Verbatim wording from the response
“The NHS Email used by the home has been reviewed and amended and no longer states Riversdale Nursing Home.”

Source location
Response from Riversdale Care Home
Page 2 · response
Published 5 November 2025
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
Notify external professionals that Riversdale is a residential care home without nurses on site.

Verbatim wording from the response
“Riversdale has not been registered as a Nursing home since 10th March 2023 it saddens us deeply that the GP practice who has supported the care home for many years was not aware of this. With this in mind we have sent correspondence to all external professionals who support the home to inform them that Riversdale is a residential care home and does not have nurses on site.”

Source location
Response from Riversdale Care Home
Page 2 · response
Published 5 November 2025
Open published response
23 Oct2025
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure of document exchange and communication between gastroenterology and cardiology teams
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progress
2. Action
  Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated planned
3. Action
  Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated planned
1. Action
  Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated completed
2. Action
  Develop and roll out the national Frontline Digitisation Programme, including electronic-record deployment guidance and support for safe implementation.
  Stated by NHS EnglandStated completed
Respondent positions 2
1. Position
  The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
  Stated by NHS EnglandOutside remit
1. Position
  Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Lynn SILCOCK · 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

Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.

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 document exchange and communication between gastroenterology and cardiology teams
Wider context from the report
“(3) There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about. ”
Source location
Lynn SILCOCK · 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
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.

Verbatim wording from the response
“The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter.”

Source location
Response from Shrewsbury and Telford Hospital
Page 2 · response
Published 19 December 2025
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
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.

Verbatim wording from the response
“In the short to medium term the Trust’s Medical Director and Deputy Medical Director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals. This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned.”

Source location
Response from Shrewsbury and Telford Hospital
Page 3 · response
Published 19 December 2025
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
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.

Verbatim wording from the response
“There will be a single referral email for each specialty for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next 3 months with SOPs developed and appropriate communications cascaded.”

Source location
Response from Shrewsbury and Telford Hospital
Page 3 · response
Published 19 December 2025
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
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.

Verbatim wording from the response
“A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the overall programme of work to mature the Trusts digital systems).”

Source location
Response from Shrewsbury and Telford Hospital
Page 4 · response
Published 19 December 2025
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
Develop and roll out the national Frontline Digitisation Programme, including electronic-record deployment guidance and support for safe implementation.

Verbatim wording from the response
“NHS England has long recognised that omissions in information-sharing within or between healthcare organisations can contribute to poor continuity of care and lead to poor health outcomes. In 2021, NHS England developed and rolled out a national ‘Frontline Digitisation’ (FD) Programme, which aimed to support NHS Trusts in England with the procurement and deployment of Electronic Patient Record (EPR) systems. The aim of this was to support increased digital maturity of organisations and improve information sharing within and between organisations. Beyond facilitating the procurement of EPR systems, the FD Programme also provided guidance and support to ensure safe and effective deployments.”

Source location
Response from NHS England
Page 1 · response
Published 19 December 2025
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 concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.

Verbatim wording from the response
“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location
Response from NHS England
Page 1 · response
Published 19 December 2025
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
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.

Verbatim wording from the response
“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location
Response from NHS England
Page 1 · response
Published 19 December 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a structured cross-team handover from ED to speciality departments

Concerns raised1

Delays or failures in delivery of ED discharge summaries

Concerns raised1

Failure to clearly communicate treatment plans and required actions in consultant correspondence

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of an easily recognised national designator for significant wider and historical health and drug-misuse risks

Fragmented sharing and updating of health and drug-misuse information across providers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to pass important risk information to the Home Treatment Team

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Lack of shared policies, guidance and understanding about information relevant for sharing between services

Failure to escalate and share increasing contact with health visitors with perinatal mental health services

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 2

Respondent positions 1

Actions described in response 4

Actions described in response 2

Actions described in response 8

Respondent positions 2