Recurring concern

Failure to communicate clinically important information reliably between care services

First to latest report 27 Sep 2013 — 10 Jun 2026

Reports that mention this concern: 144
Times this concern has been raised: 157
Stated actions linked to this concern: 271

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.

What is 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.

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.

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

Reports and published responses 144 reports

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

12 Jan2018
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to communicate relevant patient information between GP and mental health services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cornwall Partnership NHS Foundation Trust
Devon Doctors Group
NHS England
Stated actions 6
1. Cornwall Partnership NHS Foundation Trust
  Implement an assessment service with designated referral administrators who request a Patient Profile from the GP for every Adult Mental Health Services referral.
2. Cornwall Partnership NHS Foundation Trust
  Send patients and GPs written assessment outcomes describing the formulation and recommendations, with advice and signposting where secondary services are unsuitable.
3. Cornwall Partnership NHS Foundation Trust
  Use a Community Mental Health Nurse Consultant to liaise with GP practices on assessment services, team responsibilities, information sharing and raising concerns.
1. NHS England
  Work with the National Data Guardian to encourage appropriate information sharing by health and care practitioners.
2. NHS England
  Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.
3. NHS England
  Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.
Respondent positions 2
1. Cornwall Partnership NHS Foundation Trust
  Written confirmation of assessment outcomes to GPs and ongoing liaison are considered sufficient for communication about referrals.
  Existing arrangements considered sufficient
1. Devon Doctors Group
  Some information-sharing recommendations were beyond Devon Doctors’ control.
  Unable to act
AI-generated summary

David John Buttriss · 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 John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health 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
Failure to communicate relevant patient information between GP and mental health services
Wider context from the report
“1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that • There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis • The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May. • It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision. ”
Source location
David John Buttriss · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an assessment service with designated referral administrators who request a Patient Profile from the GP for every Adult Mental Health Services referral.

Verbatim wording from the response
“The Trust has implemented a new assessment service replacing the Single Point of Access to ensure that access to mental health services is consistent and effective. Each locality area now has a designated referral administrator to manage all referrals into Adult Mental Health Services and the administrator requests a copy of the Patient Profile from the patient’s GP for every referral received. Since the implementation of the assessment service some GPs now routinely provide the Patient Profile together with the referral.”

Source location
2018-0010-Response-by-Cornwall-NHS-Trust
Page 1 · response
Published 7 March 2018
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
Send patients and GPs written assessment outcomes describing the formulation and recommendations, with advice and signposting where secondary services are unsuitable.

Verbatim wording from the response
“Once the assessment has taken place and a decision made by the multi-disciplinary team as to the appropriateness for secondary mental health services a letter is sent to the patient and their GP focusing on the formulation and recommendation of the assessment. If the individual is not suitable for secondary services then advice, guidance and signposting is offered.”

Source location
2018-0010-Response-by-Cornwall-NHS-Trust
Page 1 · response
Published 7 March 2018
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
Use a Community Mental Health Nurse Consultant to liaise with GP practices on assessment services, team responsibilities, information sharing and raising concerns.

Verbatim wording from the response
“In addition ████████, in her new role as Community Mental Health Nurse Consultant, has begun working with a number of local GP practices. This has involved meeting GPs to discuss the new assessment service; the role and remit of Community Mental Health Teams and ways to improve information sharing and raising patients of concern. This is an ongoing piece of work to continue to improve liaison between services.”

Source location
2018-0010-Response-by-Cornwall-NHS-Trust
Page 2 · response
Published 7 March 2018
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
Work with the National Data Guardian to encourage appropriate information sharing by health and care practitioners.

Verbatim wording from the response
“NHS England is committed to working with the National Data Guardian to encourage health and care practitioners to share information in the interests of patients. There are clear guidelines that encourage information sharing such as the principles and recommendations published in the 2013 review of information governance in the health and care system (“To Share or Not to Share”¹). This report was conducted by Dame Fiona Caldicott who has since been appointed to be the National Data Guardian.”

Source location
2018-0010-Response-by-NHS-England
Page 1 · response
Published 7 March 2018
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
Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.

Verbatim wording from the response
“We recognise that there are many challenges across the NHS to support secure data and record sharing, and we are actively leading a number of initiatives to address this. For example, the Global Digital Exemplar (“GDE”) programme, led”

Source location
2018-0010-Response-by-NHS-England
Page 1 · response
Published 7 March 2018
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
Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.

Verbatim wording from the response
“In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings. The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient’s history of contact with the NHS and related care services. This may include information from ‘physical health checks’ for people with serious mental illness which NHS England is encouraging a greater take up of. We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations – such as GP, Acute and Social Care settings – and across geographies as the patient moves.”

Source location
2018-0010-Response-by-NHS-England
Page 2 · response
Published 7 March 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Written confirmation of assessment outcomes to GPs and ongoing liaison are considered sufficient for communication about referrals.

Verbatim wording from the response
“From the Trust’s perspective the outcome of an assessment with Adult Mental Health Services is confirmed in writing to GPs and on-going liaison work with GPs will also improve communication and information sharing.”

Source location
2018-0010-Response-by-Cornwall-NHS-Trust
Page 3 · response
Published 7 March 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Some information-sharing recommendations were beyond Devon Doctors’ control.

Verbatim wording from the response
“Dr Eggleton notes that some of your recommendations regarding information sharing are beyond the control of Devon Doctors but he is assured that our clinicians are able to make accurate assessments regarding risk, to the patient and others, and they have appropriate pathways to escalate their concerns to local mental health services. In reality this often means the patient is referred to ED to see the liaison psychiatrist team, since mental health assessments in the home environment are even more difficult to arrange out of hours than they are in hours.”

Source location
2018-0010-Response-by-Devon-Doctors
Page 1 · response
Published 7 March 2018
Open published response
9 Nov2017
South Yorkshire (Western)
Concerns raised1
1. Failure of communication and information sharing between CAMHS and Adult Services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department of Health and Social Care
Sheffield Children'S NHS Foundation Trust
Sheffield Health Partnership University NHS Foundation Trust
Stated actions 1
1. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Resolve governance and technical barriers to establish information exchange between CAMHS and adult emergency services.
Respondent positions 1
1. Department of Health and Social Care
  Local commissioners and providers are responsible for ensuring timely information sharing, communication and joint working between mental health services.
  Redirects responsibility
AI-generated summary

Daisy French · 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

Daisy French, who had a history of serious mental health difficulties and was transitioning from child to adult mental health services, died after deliberately placing herself in front of a high-speed train at Meadowhall Railway Station on 19 April 2017. The concerns included communication and information sharing between services, transition of care, differing out-of-hours arrangements for 16- to 18-year-olds, placement of an under-18-year-old in an adult crisis house, and returning her to accommodation without staff on duty after a mental health assessment.

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 communication and information sharing between CAMHS and Adult Services
Wider context from the report
“1) The communication/information sharing between CAMHS and Adult Services. ”
Source location
Daisy French · 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
Resolve governance and technical barriers to establish information exchange between CAMHS and adult emergency services.

Verbatim wording from the response
“Current information sharing between Child and Adolescent Mental Health Services (CAMHS) and the Adult Services can and does take place via telephone calls or written letters. As CAMHS and the adult services/Trusts have different IT patient record systems, it presents a challenge for each service to be accessed by the other. Also, each Trust’s fire wall and data protection governance systems prevents Sheffield Teaching Hospital’s (STH) and SHSC staff accessing CAMHS patient records (as held by SC NHS FT) and CAMHS accessing the adult Emergency Department (as held by STH) records to ascertain which CAMHS patients have recently attended the Emergency Department (ED) at STH.”

Source location
2017-0264-Response-by-Sheffield-Health-and-Social-Care
Page 1 · response
Published 9 November 2017
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
Local commissioners and providers are responsible for ensuring timely information sharing, communication and joint working between mental health services.

Verbatim wording from the response
“Local commissioners and providers are responsible for ensuring processes and systems support the appropriate and timely sharing of information, communication and joint working to meet the needs of people who require support. This includes mental health services.”

Source location
2017-0264-Response-by-Department-of-Health
Page 2 · response
Published 9 November 2017
Open published response
23 Oct2017
Inner North London
Concerns raised1
1. Disjointed coordination of care between crisis house and crisis team services
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

North London NHS Foundation Trust
Stated actions 3
1. North London NHS Foundation Trust
  Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
2. North London NHS Foundation Trust
  Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
3. North London NHS Foundation Trust
  Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Respondent positions 1
1. North London NHS Foundation Trust
  Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
  Existing arrangements considered sufficient
AI-generated summary

Siân Louise WITHERIDGE · 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

Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

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
Disjointed coordination of care between crisis house and crisis team services
Wider context from the report
“6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust. For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave. ”
Source location
Siân Louise WITHERIDGE · 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
Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.

Verbatim wording from the response
“We agree that Highbury Grove Crisis House staff should have access to our clinical records. To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”

Source location
2017-0305-Response
Page 1 · response
Published 27 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.

Verbatim wording from the response
“We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.”

Source location
2017-0305-Response
Page 2 · response
Published 27 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.

Verbatim wording from the response
“We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.”

Source location
2017-0305-Response
Page 2 · response
Published 27 November 2017
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
Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.

Verbatim wording from the response
“We are aware that Highbury Grove has sent you our ‘Working Protocol’ setting out how our teams work together. As set out earlier, we accept that there have been challenges with information sharing. We are confident however that this has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information.”

Source location
2017-0305-Response
Page 3 · response
Published 27 November 2017
Open published response
5 Oct2017
North West Wales
Concerns raised1
1. Delay in sending discharge information to the GP
This report raised 7 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

Simon Willans · 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

Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.

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
Delay in sending discharge information to the GP
Wider context from the report
“(4) There is insufficient safety netting for this patient. He was not told what to do in the event of a worsening of his condition. The letter to the GP was faxed the day after discharge by which time he had died ”
Source location
Simon Willans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Sep2017
London Inner (West)
Concerns raised1
1. Failure to coordinate pre-discharge handover and transition with the GP surgery
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Jackie Doyle-Price MP
South West London and St George'S Mental Health NHS Trust
Stated actions 2
1. South West London and St George'S Mental Health NHS Trust
  Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.
2. South West London and St George'S Mental Health NHS Trust
  Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.
Respondent positions 1
1. Jackie Doyle-Price MP
  Operational concerns about discharge and communication are the responsibility of the relevant NHS Trust.
  Redirects responsibility
AI-generated summary

GILLIAN O’KEEFFE · 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

Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.

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 coordinate pre-discharge handover and transition with the GP surgery
Wider context from the report
“(3) There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery. ”
Source location
GILLIAN O’KEEFFE · 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
Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.

Verbatim wording from the response
“We have provided rationale for the decision to discharge but also acknowledge that more engagement should have taken place with key stakeholders prior to Mrs O’Keefe’s discharge. Since this incident, our Clinical Disengagement/Did Not Attend Policy has been updated. The updated version is more prescriptive with regards to what actions need to be taken before a patient can be discharged and this includes engagement with the GP and inclusion of the GP in the decision to discharge. Adherence to this policy is audited through our clinical audit programme.”

Source location
2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Page 2 · response
Published 3 October 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.

Verbatim wording from the response
“The Trust’s revised Clinical Disengagement/Did Not Attend Policy states that the team should liaise with the GP and invite them to be involved in the decision to discharge the patient.”

Source location
2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Page 3 · response
Published 3 October 2017
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
Operational concerns about discharge and communication are the responsibility of the relevant NHS Trust.

Verbatim wording from the response
“The matters raised are operational and relate to the South West London & St George’s Mental Health NHS Trust. However, it is important to make clear the national policy expectations in relation to the issues you have raised.”

Source location
2017-0233-Response-by-Department-of-Health
Page 1 · response
Published 3 October 2017
Open published response
21 Sep2017
Derby and Derbyshire
Concerns raised1
1. Failure to communicate confirmed fractures and necessary care measures to relevant care providers
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Barbara Christine Sturgess · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Barbara Christine Sturgess, who had advanced dementia and was at high risk of falls, sustained a cervical spinal fracture in a fall at her nursing home on 20 May 2017 and died of bronchopneumonia on 8 June 2017. The hospital did not initially inform the nursing home or GP practice of the fracture or necessary care measures; although this was not evidenced to have contributed to her death, it had the potential to adversely affect her wellbeing and could contribute to death in similar cases.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate confirmed fractures and necessary care measures to relevant care providers
Wider context from the report
“The Chesterfield Royal Hospital did not inform the nursing home or the GP practice that Barbara Christine Sturgess had sustained a cervical spinal fracture nor of any necessary measures in her care and treatment. Her daughter attended a fracture clinic appointment with her on 24 May 2017 where a Doctor told the daughter that a fracture had been sustained and that care should be exercised in her management on account of the fracture. It was only on 26 May 2017, as a result of enquiries by the nursing home, that formal confirmation of the fracture was provided by the hospital. Although there was no evidence that the failure of the hospital to properly confirm and advise on the fracture was a factor in Barbara Christine Sturgess’s death this did have the potential to adversely affect her wellbeing. Very importantly if there were to be further similar failings in communication it could be that for some patients this could be a contributory factor in death. ”
Source location
Barbara Christine Sturgess · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Jul2017
South Wales Central
Concerns raised2
1. Failure to reliably communicate medication and clinical plans from hospital to care home
2. Fragile communication system between GP, hospital and care home
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Care Quality Commission
Healthcare Inspectorate Wales
RHAYADER GROUP PRACTICE
Stated actions 6
1. Healthcare Inspectorate Wales
  Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.
2. Care Quality Commission
  Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
3. Care Quality Commission
  Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
1. Care Quality Commission
  Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
2. Healthcare Inspectorate Wales
  Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.
3. RHAYADER GROUP PRACTICE
  Fast-track medical records for new patients registering at nursing or care homes so doctors receive prior medical history promptly.
Respondent positions 1
1. Care Quality Commission
  Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.
  Existing arrangements considered sufficient
AI-generated summary

Percy Jacks · 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

Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.

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 reliably communicate medication and clinical plans from hospital to care home
Wider context from the report
“(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home. ”
Source location
Percy Jacks · 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
Fragile communication system between GP, hospital and care home
Wider context from the report
“(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time. ”
Source location
Percy Jacks · 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
Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.

Verbatim wording from the response
“I note the concerns raised by the report regarding fragile communication between health services and the care home and will discuss further with CSSIW how we may seek to collaborate and address this issue jointly through our work.”

Source location
2017-0329-Response-by-Welsh-Government
Page 1 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.

Verbatim wording from the response
“As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.”

Source location
2017-0329-Response-by-Care-Quality-Commission
Page 6 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.

Verbatim wording from the response
“We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

Source location
2017-0329-Response-by-Care-Quality-Commission
Page 4 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.

Verbatim wording from the response
“We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

Source location
2017-0329-Response-by-Care-Quality-Commission
Page 4 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.

Verbatim wording from the response
“HIW has noted the findings of the inquest and assure you that this information will be used to inform our work. HIW is currently undertaking a review of discharge arrangements focusing on communication and the quality of documentation used to support patient discharge from secondary to primary healthcare. I can confirm that this report has been shared with the review lead to consider.”

Source location
2017-0329-Response-by-Welsh-Government
Page 1 · response
Published 2 December 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Fast-track medical records for new patients registering at nursing or care homes so doctors receive prior medical history promptly.

Verbatim wording from the response
“We have discussed this in our practice meeting and have made the following changes.”

Source location
2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017
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
Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.

Verbatim wording from the response
“As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.”

Source location
2017-0329-Response-by-Care-Quality-Commission
Page 6 · response
Published 2 December 2017
Open published response
17 Jul2017
Manchester South
Concerns raised1
1. Delays in dispatching discharge summaries
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions 3
1. Tameside and Glossop Integrated Care NHS Foundation Trust
  Deploy additional resources to clear the discharge-summary backlog and restore timely completion.
2. Tameside and Glossop Integrated Care NHS Foundation Trust
  Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
3. Tameside and Glossop Integrated Care NHS Foundation Trust
  Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.
Respondent positions 1
1. Tameside and Glossop Integrated Care NHS Foundation Trust
  Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
  Existing arrangements considered sufficient
AI-generated summary

Matthew Robert Edwards · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in dispatching discharge summaries
Wider context from the report
“1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result, Matthew Edwards GP was not notified about his period as an in patient. When he attended a subsequent GP appointment, she was unclear about the discharge plan for Mr Edwards and the rationale for it. ”
Source location
Matthew Robert Edwards · 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
Deploy additional resources to clear the discharge-summary backlog and restore timely completion.

Verbatim wording from the response
“In order to bring the position back to a baseline from which the Trust could confidently move forwards with new processes, extra resources were brought in to clear a backlog that had regrettably developed with discharge summaries. I wish to assure you that the Trust fully recognises the importance of discharge summaries as a handover of care between different organisations and services involved in the care of a patient. I was disappointed to learn that a backlog had developed due to other organisational pressures and asked my Executive team to take immediate steps to identify the source of the problem and remedy it as swiftly as possible.”

Source location
Matthew-Edwards-Response
Page 1 · response
Published 17 July 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.

Verbatim wording from the response
“I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.”

Source location
Matthew-Edwards-Response
Page 2 · response
Published 17 July 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.

Verbatim wording from the response
“The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from Brendan Ryan, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the Consultant responsible for that episode of care, and this has been reiterated to all consultants. Compliance is being monitored by the Trust's Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made and maintained.”

Source location
Matthew-Edwards-Response
Page 2 · response
Published 17 July 2017
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 discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.

Verbatim wording from the response
“This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.”

Source location
Matthew-Edwards-Response
Page 3 · response
Published 17 July 2017
Open published response
16 Jun2017
Liverpool and the Wirral
Concerns raised1
1. Failure to ensure effective information exchange during mental health service transfers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Mersey Care NHS Foundation Trust
Stated actions 3
1. Mersey Care NHS Foundation Trust
  Amend the transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.
2. Mersey Care NHS Foundation Trust
  Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.
3. Mersey Care NHS Foundation Trust
  Consider including an audit of transfer processes in the Junior Doctor Audit programme.
AI-generated summary

Lee Joseph Hastings Swain · 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

Lee Joseph Hastings-Swain, aged 28, was found deceased hanging from a bannister at his home on 30 November 2016. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included inadequate coordination and information-sharing between mental health services, delays in referral, poor clinical records, and insufficiently proactive engagement after his transfer between NHS trusts.

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 ensure effective information exchange during mental health service transfers
Wider context from the report
“A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. ”
Source location
Lee Joseph Hastings Swain · 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 transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.

Verbatim wording from the response
“Mersey Care NHS Foundation Trust (MCFT) response I have enclosed the key changes that have been made to policy following the Regulation 28 report at Appendix 1.”

Source location
2017-0196-Mersey-Care-NHS-Trust
Page 2 · response
Published 11 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.

Verbatim wording from the response
“I can confirm that the outcome of the inquest hearing and the required changes to the policy have been circulated within MCFT through operational management meetings, consultant forums and via Quality Practice Alert (QPA). I can also confirm that the QPA was issued prior to the Inquest hearing on 16th March 2017 as part of the Trust’s processes of learning from this incident. This included clear guidance on what is expected of teams when a patient is being transferred from one organisation to another. The contents of the QPA included:-”

Source location
2017-0196-Mersey-Care-NHS-Trust
Page 2 · response
Published 11 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consider including an audit of transfer processes in the Junior Doctor Audit programme.

Verbatim wording from the response
“An audit of transfer processes based on the amended policies will be considered for inclusion in each Trust’s Junior Doctor Audit programme.”

Source location
2017-0196-Mersey-Care-NHS-Trust
Page 2 · response
Published 11 August 2017
Open published response
5 Jun2017
Manchester South
Concerns raised1
1. Limited information sharing between health professionals to identify service access and need for psychiatric referral
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Grosvenor Medical Centre
Stated actions 1
1. Grosvenor Medical Centre
  Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
AI-generated summary

David Ian Hamilton · 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 Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.

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
Limited information sharing between health professionals to identify service access and need for psychiatric referral
Wider context from the report
“3. The system of sharing information between health professionals (the GP and Healthy Minds) to identify if the correct services were being accessed or if a referral to a psychiatrist was required was limited and meant that those involved did not have a full picture of his mental health; ”
Source location
David Ian Hamilton · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.

Verbatim wording from the response
“3) We have also written to the Mental Health Lead to ask for improved communication between the Healthy Minds and the GPs.”

Source location
2017-0180-Response-by-Grosvenor-Medical-Centre
Page 2 · response
Published 4 August 2017
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 communicate relevant patient information between GP and mental health services

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

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

Concerns raised1

Failure of communication and information sharing between CAMHS and Adult Services

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised1

Disjointed coordination of care between crisis house and crisis team services

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised1

Delay in sending discharge information to the GP

Concerns raised1

Failure to coordinate pre-discharge handover and transition with the GP surgery

Linked responses

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

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

Concerns raised1

Failure to communicate confirmed fractures and necessary care measures to relevant care providers

Concerns raised2

Failure to reliably communicate medication and clinical plans from hospital to care home

Fragile communication system between GP, hospital and care home

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

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

Stated actions 6

Respondent positions 2

Stated actions 1

Respondent positions 1

Stated actions 3

Respondent positions 1

Stated actions 2

Respondent positions 1

Stated actions 6

Respondent positions 1