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.

Reports and published responses 144 reports

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

  1. Manchester South

    AI-generated summary

    Antony Williamson · 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

    Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex 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 of specialties to communicate about patients’ plans and actions

    Wider context from the report

    “Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr Williamson’s care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others. The inquest was told that there is a significant proportion of patients who are referred to the Pain Service who suffer poor mental health and who are therefore also under the care of mental health teams in the community. The inquest heard that there is no formal framework (other than in cancer care and one specialist area of surgery) either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases and further, that the existing channels of communication are more problematic between different NHS Trusts even within the same geographical area. ”

    Source location

    Antony Williamson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Essex

    AI-generated summary

    MARY MARGARET WHITLOCK · 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

    Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide discharge summaries to care homes

    Wider context from the report

    “(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury ”

    Source location

    MARY MARGARET WHITLOCK · 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

    Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.

    Verbatim wording from the response

    “Following Mrs Whitlock’s experience, all our Emergency Medicine clinicians have been reminded of the requirement to complete a discharge summary to all patients in every case. We have highlighted the importance of these being available to patients who are not being discharged to their own home.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 3 · response
    Published 19 December 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind nursing staff to verify discharge-summary completion before patients leave the department.

    Verbatim wording from the response

    “Nursing colleagues have also been reminded to check that this has been completed prior to the patient leaving the department upon discharge.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 3 · response
    Published 19 December 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.

    Verbatim wording from the response

    “We have included the learning from Mrs Whitlock’s case within our all-staff patient safety bulletin for January 2025 emphasising the importance of a full and accurate discharge summary being completed at the point of discharge.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 3 · response
    Published 19 December 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.

    Verbatim wording from the response

    “We plan to monitor our performance with issuing discharge summaries within our 2025 trust-wide corporate audit programme to assure ourselves with compliance and use the results to take action as appropriate.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 3 · response
    Published 19 December 2024

    Open published response

  3. Cambridgeshire and Peterborough

    AI-generated summary

    Patricia CURTIS · 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

    Patricia Curtis underwent complex cardiac surgery and was transferred to Bedford Hospital, where she deteriorated rapidly and died from a haemothorax identified at post-mortem examination. The report states that a haemothorax was not included in the differential diagnosis when clinical signs first appeared. It also raises concern that non-uniform hospital discharge notes may result in essential information being unavailable after transfer between hospitals, potentially delaying life-saving care and treatment.

    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

    Unavailability of essential patient information to treating clinicians in new clinical settings

    Wider context from the report

    “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment. ”

    Source location

    Patricia CURTIS · 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

    Publish national statutory hospital discharge guidance requiring safe, timely discharge and accurate information sharing across organisational boundaries.

    Verbatim wording from the response

    “While individual trusts are responsible for their own discharge policies, national statutory hospital discharge guidance has been published (last updated January 2024) which details the national discharge requirements for all NHS Trusts, commissioning bodies, local”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 December 2024

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Bryan Andrews and Mary Andrews · 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

    Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

    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 clinically relevant information between services about epilepsy and psychosis

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · 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

    Failure to send discharge summaries to the General Practitioner

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · 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

    Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.

    Verbatim wording from the response

    “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:”

    Source location

    Response from Sheffield Health and Social Care
    Page 1 · response
    Published 8 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.

    Verbatim wording from the response

    “2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge”

    Source location

    Response from Sheffield Health and Social Care
    Page 1 · response
    Published 8 October 2024

    Open published response

  5. West Sussex, Brighton and Hove

    AI-generated summary

    Ryan Louis Ouslem · 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

    Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

    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 share all relevant information with mental health practitioners in a timely manner

    Wider context from the report

    “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner. An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training. I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police. SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service. I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide. Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask. ”

    Source location

    Ryan Louis Ouslem · 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

    Operate the newly implemented Rapid Response Service through a single point of contact to support consistent guidance and information sharing with police.

    Verbatim wording from the response

    “The soft launch of the RRS went live on 4 November 2024.”

    Source location

    Response from Sussex Partnership NHS Trust
    Page 2 · response
    Published 25 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue monitoring information sharing between the Trust and Sussex Police through the Rapid Response Service.

    Verbatim wording from the response

    “Prior to the launch of the RRS, representatives from the Trust met with Sussex Police's Mental Health Lead and a representative from West Sussex Fire and Rescue Service on 16 July 2024 which enabled a discussion of how it was anticipated the RRS would function when launched on 4 November 2024. One of the conclusions from the meeting was that there is scope for improvement of the flow of information between the police and mental health services and I address below the action the Trust has taken (and will continue to monitor) to make these improvements.”

    Source location

    Response from Sussex Partnership NHS Trust
    Page 2 · response
    Published 25 September 2024

    Open published response

  6. Inner North London

    AI-generated summary

    Laura Lesley FARMER · 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

    Laura Farmer was admitted to hospital after a diarrhoeal illness and was diagnosed with HUS caused by Shiga toxin-producing E. coli. She suffered an unexpected stroke while thought to be recovering and died as a consequence. The report raises concerns about public-health investigation and communication, including limited information-gathering, lack of feedback to clinicians and family, and insufficient advice on infection-control and safety.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide treating clinicians with public health investigation feedback and infection-control information

    Wider context from the report

    “4. The clinicians treating Ms Farmer gave evidence at inquest that they did not know if the source of the infection that killed her had ever been identified. Mr Farmer saw in the news that there was a local E coli outbreak in Waverley, Surrey. The clinicians at UCLH knew which strain of E coli had infected Ms Farmer, but not whether that strain had been discovered in Waverley or indeed elsewhere, because after reporting to the UKHSA they received no feedback, no advice on infection control and no information they could give Mr Farmer. After a death from E coli, there seems to have been no closing of the loop of safety information that could have assisted those most closely involved. ”

    Source location

    Laura Lesley FARMER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The expectation that UKHSA should disseminate information to clinicians and family was unfair because it did not reflect UKHSA policies or procedures.

    Verbatim wording from the response

    “34. We acknowledge the Senior Coroner’s expectation that UKHSA share relevant information with both clinicians and the family. However, without information about our role or any UKHSA representation at the inquest, we believe this expectation has led to an unfair observation. Paragraph 25 of The Chief Coroner’s Guidance Note No.5 states that a Coroner, when reporting, should “…base their report on clear evidence at the inquest or on clear information during the investigation, to express clearly and simply what that information or evidence is, and to ensure that a bereaved family’s expectations are not raised unrealistically.” The lack of UKHSA evidence and representation at the inquest, in our view, would cause difficulty in expressing clearly and simply when, how and who information should have been disseminated to.”

    Source location

    Response from UK Health Security Agency
    Page 7 · response
    Published 17 September 2024

    Open published response

  7. West Sussex, Brighton and Hove

    AI-generated summary

    Miles Ethan Hurley · 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

    Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

    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

    Difficulty obtaining collateral mental health information from other services

    Wider context from the report

    “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite. a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care. b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody. c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody. c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment. d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody. d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present. e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 7 · 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

    Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.

    Verbatim wording from the response

    “f) NHS Trust information sharing has also been raised as a concern by the NPCC in that the inability or refusal to share clinical records between criminal justice pathways adds risk to a detainees welfare.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 29 July 2024

    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

    Sussex Partnership Trust’s Mental Health Helpline is best placed to respond about family information not being shared with the commissioned Liaison and Diversion service.

    Verbatim wording from the response

    “7. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 29 July 2024

    Open published response

  8. West Sussex, Brighton and Hove

    AI-generated summary

    Lee Spencer PURKIS · 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 Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other 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 of probation oversight to ensure awareness and proper administration of mental health treatment requirements

    Wider context from the report

    “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly. ”

    Source location

    Lee Spencer PURKIS · 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

    Failure to transfer and communicate mental health treatment requirements to receiving Trusts

    Wider context from the report

    “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly. ”

    Source location

    Lee Spencer PURKIS · 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

    Collaborate with the Forensic and Specialist Directorate to examine Kent Secondary Care Mental Health Treatment Requirement practice and responsibilities across the intervention.

    Verbatim wording from the response

    “More specifically in Kent we have begun collaborating with the Service Director of the Forensic and Specialist Directorate to explore current practice with Secondary Care MHTRs from pre-sentence stage through to delivery of the treatment requirement and the roles both Probation and Secondary Care play in the intervention. We aim to upskill Secondary Care Responsible Clinicians and Probation Court and Sentence Management staff to ensure we are identifying the right people at Court who may benefit from this Order and overseeing the case in a robust manner.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 8 August 2024

    Open published response

  9. Suffolk

    AI-generated summary

    Regan Edwin James SMITH · 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

    Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of 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 of patient handover processes to ensure significant clinical findings are available to receiving clinicians

    Wider context from the report

    “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023. Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians. Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case. It was heard that Regan’s verbal only handover occurred during a period of very high acuity. On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor. It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units. In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel. ”

    Source location

    Regan Edwin James SMITH · 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

    Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.

    Verbatim wording from the response

    “The rapid exchange of clinical information verbally remains an integral part of communication. However, work is ongoing with NHSE to provide IT support that can deliver improved sharing of electronic information across systems. Linking the ambulance computer aided despatch system and electronic patient record collected by ambulance services with emergency departments data will provide better information about the patient journey.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 4 September 2024

    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 and oversight of clinical handover protocols across England are the responsibility of local organisations.

    Verbatim wording from the response

    “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 4 September 2024

    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 process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.

    Verbatim wording from the response

    “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 4 September 2024

    Open published response

  10. Oxfordshire

    AI-generated summary

    Caroline Diane Harris · 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

    Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.

    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 share information regarding deterioration in mental health with the appropriate team

    Wider context from the report

    “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’. MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT. Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act. My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. You should consider a review of how such information is assessed and shared between the respective agencies. ”

    Source location

    Caroline Diane Harris · 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

    Email Adult Mental Health Teams when online records are unavailable, follow up until a decision is received, and escalate unsuccessful contact to team leaders.

    Verbatim wording from the response

    “3. Where access to online records like RIO for mental health, is not possible the team must immediately email AMHT to check for mental health involvement before action is taken. The Social and Health Care Team will continue to follow up with AMHT until a response and decision is reached. In the unlikely event that contact cannot be made with AMHT, this is escalated to Team Leaders who will contact their counterparts in AMHT.”

    Source location

    Response from Oxfordshire County Council
    Page 7 · response
    Published 17 July 2026

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026