Recurring concern

Failure to communicate clinically important information reliably between care services

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First reported 27 Sep 2013•Latest report 10 Jun 2026

Definition

What this concern includes

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

Not included

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

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

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care25

NHS England24

Essex Partnership University NHS Foundation Trust5

Greater Manchester Mental Health NHS Foundation Trust5

NHS Greater Manchester Integrated Care Board5

Pennine Care NHS Foundation Trust5

Care Quality Commission4

Manchester University NHS Foundation Trust4

Aneurin Bevan University LHB3

Birmingham and Solihull Mental Health NHS Foundation Trust3

Cheshire and Wirral Partnership NHS Foundation Trust3

Health Services Safety Investigations Body3

Mid and South Essex NHS Foundation Trust3

Midlands Partnership University NHS Foundation Trust3

North West Ambulance Service NHS Trust3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

25 Apr2017
Inner North London
Concerns raised1
1. Failure to verify treatment information with external mental health service providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Distribute guidance to City and Hackney clinical staff on contacting external mental health providers.
  Stated by East London NHS Foundation TrustStated completed
AI-generated summary

Jamie Neil Elliott · 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

Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

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 verify treatment information with external mental health service providers
Wider context from the report
“1. Mental health clinicians from the Trust should be required to contact external providers of mental health services, if possible, when a patient is receiving treatment elsewhere, particularly when consideration is being given to compulsorily detain that individual. They should not simply take the patient’s account at face value. ”
Source location
Jamie Neil Elliott · 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
Distribute guidance to City and Hackney clinical staff on contacting external mental health providers.

Verbatim wording from the response
“In relation to contact with external providers I can confirm that a memo has been distributed to all clinical staff in City and Hackney highlighting the issue.”

Source location
2017-0135-Response-by-East-London-NHS-Trust
Page 1 · response
Published 10 July 2017
Open published response
18 Apr2017
Surrey
Concerns raised2
1. Failure to routinely share clinical assessment records with receiving community mental health services outside the county
2. Failure to provide timely access to patient information held by mental health services in other counties
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Daniel Maher · 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

Daniel Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.

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 routinely share clinical assessment records with receiving community mental health services outside the county
Wider context from the report
“During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. - The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. - The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection. - As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey. Consideration should be given to whether any steps can be taken to address the above concerns. ”
Source location
Daniel Maher · 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 provide timely access to patient information held by mental health services in other counties
Wider context from the report
“During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. - The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. - The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection. - As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey. Consideration should be given to whether any steps can be taken to address the above concerns. ”
Source location
Daniel Maher · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Mar2017
Portsmouth and South East Hampshire
Concerns raised1
1. Failure to email endoscopy discharge summaries to GP practices
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Beryl Yvonne Foster · 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

Beryl Yvonne Foster underwent an endoscopic ultrasound examination on 8 December 2015, became unwell after discharge, was readmitted on 11 December 2015, and died on 2 January 2016. The concern was that posting, rather than emailing, the endoscopy discharge summary meant her GP practice was unaware of the procedure when she contacted it after becoming unwell, creating a risk in similar circumstances.

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 email endoscopy discharge summaries to GP practices
Wider context from the report
“Mrs Foster's discharge summary was handed to her on 8 December 2015 and was subsequently posted to her GP practice. This meant that when she became unwell the following day and contacted the practice, it was unaware of the endoscopy the previous day. I was told that endoscopy discharge summaries are posted to GP practices by QAH, rather than emailed like all other discharge summaries. I am concerned this practice raises a risk that future deaths will occur in such circumstances and I would ask the NHS Trust to consider emailing all discharge summaries to GP practices in the future. ”
Source location
Beryl Yvonne Foster · Prevention of Future Deaths report
Page 1 · concerns
Open source report
28 Mar2017
South Lincolnshire
Concerns raised1
1. Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completed
2. Action
  Issue and recirculate standards for communicating test results between secondary and primary care.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completed
3. Action
  Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completed
1. Action
  Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completed
2. Action
  Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progress
Respondent positions 1
1. Position
  Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustUnable to act
AI-generated summary

Olive DAYNES · 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

Olive Daynes, described as an 86-year-old lady, presented to hospital with an altered mental state and a suspected fall after earlier treatment for painful or sore legs and ulcers. The report identified concerns about Warfarin being prescribed with antibiotics, inadequate monitoring, communication between the hospital and GP surgery, and a subsequent INR increase to over 9 before she passed away.

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 hospital advice, medication changes and increased INR levels to the GP in time
Wider context from the report
“1. On 28/12/2015 Mrs. Daynes was admitted to Accident and Emergency at the Pilgrim Hospital, Fishtoft, and Boston following painful / sore legs/ulcers. 2. Her INR was recorded at 3.6, her medication changed and the matter was referred back to the GP. 3. A doctor from the GP's surgery saw Mrs Daynes the next day on 29th December 2015 but was unaware of the advice provided by the hospital, change in medication or increased IRN levels. 4. The hospital wrote to the surgery and the letter arrived on 4/2/2016 (date stamp verified by the Coroner). 5. In the intervening period the patients INR increased to over 9 and she passed away on 5/1/2016. ”
Source location
Olive DAYNES · 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
Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.

Verbatim wording from the response
“5. In order to prevent similar deaths in the future, the discharge letter is sent by electronic means to the appropriate GP email address of the appropriate GP surgery.”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 1 · response
Published 5 April 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
Issue and recirculate standards for communicating test results between secondary and primary care.

Verbatim wording from the response
“7. In 2016 the Trust and the Lincolnshire Local Medical Committee issued a document setting the standards and principles by which test results should be communicated by secondary and primary care. I enclose a copy of this document which was sent to all clinicians within ULHT. This has been circulated again to remind colleagues of their responsibilities.”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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 an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.

Verbatim wording from the response
“8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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
Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.

Verbatim wording from the response
“8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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
Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.

Verbatim wording from the response
“9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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
Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.

Verbatim wording from the response
“9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:”

Source location
Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 2017
Open published response
17 Mar2017
Preston and West Lancashire
Concerns raised1
1. Failure of mental health and substance misuse services to share patient information
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Stephen McDermott · 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

Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

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 mental health and substance misuse services to share patient information
Wider context from the report
“7) It was apparent that when patients are assessed and treated by other services, in this case Discover Drug and Alcohol Recovery Services provided by Greater Manchester West NHS Foundation Trust [‘GMW’], LCFT do not have access to GMW records and vice versa. In a case such as this, where there is a significant overlap between mental health issues and substance misuse issues, it is of significant concern that services do not / cannot share information to assist in their assessment processes to ensure that they are in possession of the full picture of an individual’s presentation; ”
Source location
Stephen McDermott · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Dec2016
Gwent
Concerns raised1
1. Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mrs Georgina Lewis · Prevention of Future Deaths report

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

Report summary

Mrs Georgina Lewis was discharged from a psychiatric unit on 23 September 2013, went missing from home on 27 September, and was found dead in woods near her home on 30 September 2013. Concerns included discharge without family consultation, no discharge plan or follow-up support, and delayed notification to her GP.

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 the GP with contemporaneous notification of discharge and the assessment leading to discharge
Wider context from the report
“(3) There was no contemporaneous notification to her GP of the discharge or the assessment leading to discharge, in fact the GP had still not received notification by the time of discovery of Mrs Lewis body ”
Source location
Mrs Georgina Lewis · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Dec2016
Cheshire
Concerns raised1
1. Inadequate communication and liaison between hospital and community care providers after discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Charles Ray Woodward · 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

Charles Ray Woodward underwent surgery to remove a sigmoid colon tumour and was discharged home after an apparently uneventful recovery. His health then declined, and he died from peritonitis caused by a leaking anastomosis following surgery. The principal concerns were inadequate communication and liaison between the hospital, community care providers and the family, together with insufficiently robust monitoring of his condition after discharge.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate communication and liaison between hospital and community care providers after discharge
Wider context from the report
“There was inadequate communication and liaison between the hospital on the one hand and on the other hand the deceased’s GP practice and district nurses in the community who, following the deceased’s discharge from hospital, would be responsible for the deceased’s ongoing care. Further, monitoring of the deceased’s condition from Leighton Hospital was insufficiently robust and relied upon oral contact rather than ensuring the physical presence of a medical attendant, be that attendant hospital or community based. The evidence suggested that there was miscommunication between the hospital and the deceased’s family with the result that the deceased’s worrying decline in health was not appreciated by the hospital. ”
Source location
Charles Ray Woodward · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Oct2016
Birmingham and Solihull
Concerns raised1
1. Failure to communicate relevant clinical information between hospitals
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
  Stated by the Dudley Group NHS Foundation TrustStated completed
2. Action
  Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
  Stated by the Dudley Group NHS Foundation TrustStated completed
3. Action
  Deliver the agreed cross-Trust action plan to address identified safety concerns.
  Stated by the Dudley Group NHS Foundation TrustStated in progress
1. Action
  Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
AI-generated summary

Alfie Rose · 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

Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate relevant clinical information between hospitals
Wider context from the report
“1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen. ”
Source location
Alfie Rose · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.

Verbatim wording from the response
“It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:”

Source location
2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Page 2 · response
Published 26 October 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.

Verbatim wording from the response
“Issues Identified:”

Source location
2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Page 2 · response
Published 26 October 2016
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
Deliver the agreed cross-Trust action plan to address identified safety concerns.

Verbatim wording from the response
“A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT. We have commenced on the delivery of these actions and recorded our progress on the action plan for you information.”

Source location
2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Page 2 · response
Published 26 October 2016
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
Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.

Verbatim wording from the response
“It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:”

Source location
2016-0382-Response-by-University-Hospitals-Birmingham-NHS-Trust
Page 2 · response
Published 26 October 2016
Open published response
8 Jun2016
South Yorkshire (Eastern)
Concerns raised1
1. Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Undertake a compliance review of the information-transfer procedure to confirm full implementation of the system.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
3. Action
  Share the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
AI-generated summary

Anthony Benjamin Patrick Fraser · Prevention of Future Deaths report

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

Report summary

Anthony Benjamin Patrick Fraser had terminal multiple myeloma and died at Doncaster Royal Infirmary on 24 September 2015 after his condition significantly progressed and palliative care was initiated. The report identified the absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness, which could delay diagnosis for other inmates.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers
Wider context from the report
“I heard evidence that the medical records on the electronic Spine One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser’s case when he was referred to A&E on 15th August 2015, this information was not conveyed by them to the receiving hospital. I also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent. Whilst I concluded that in Mr Fraser’s case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis. Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion. Summary of concerns:- 1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. . ”
Source location
Anthony Benjamin Patrick Fraser · 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
Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.

Verbatim wording from the response
“Following the receipt of the Regulation 28 Report, a collaborative meeting took place with the Governor of HMP Lindholme, ████████ and the Associate Director for Offender Health, ████████ and the Head of Healthcare at HMP Lindholme, ████████ and the Head of Security at HMP Lindholme, ████████. The purpose of the meeting was to develop a shared system to address the concerns you have raised in the Preventing Future Deaths report.”

Source location
2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Page 2 · response
Published 8 June 2016
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 compliance review of the information-transfer procedure to confirm full implementation of the system.

Verbatim wording from the response
“A procedure was co-authored by the group, clearly identifying the roles and responsibilities of both Custodial and Healthcare staff. A copy of the procedure has been included with this letter. The procedure has been issued to staff and is now in operation. A review of compliance will be undertaken by the Head of Healthcare within the coming month, to ensure we have achieved full implementation for a robust system of conveying summary medical information to A&E depts.”

Source location
2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Page 2 · response
Published 8 June 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.

Verbatim wording from the response
“A copy of the procedure will be shared at the Offender Health Learning the Lessons Forum on the 9th of September 2016, to ensure colleagues in other establishments also have a system in place for the transfer of medical information, thereby avoiding future deaths.”

Source location
2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Page 2 · response
Published 8 June 2016
Open published response
1 Apr2016
Essex
Concerns raised1
1. Failure to communicate relevant dementia information to transport and support services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mr Roy Henry Oakley · Prevention of Future Deaths report

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

Report summary

Mr Roy Henry Oakley was taken to Orsett Hospital for a routine blood test and, after being told to wait in the coffee shop without a settled collection arrangement, went to the ambulance bays and suffered an accident. He died on 12 June 2015. The report identified concerns that his dementia was not communicated to the transport and phlebotomy services, that no carer had been arranged to attend with him, and that information-sharing limitations may have played some part in his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate relevant dementia information to transport and support services
Wider context from the report
“TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him. During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia. The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia. Other commissioned out services are in a similar position. The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley. ”
Source location
Mr Roy Henry Oakley · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to verify treatment information with external mental health service providers

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

Concerns raised2

Failure to routinely share clinical assessment records with receiving community mental health services outside the county

Failure to provide timely access to patient information held by mental health services in other counties

Concerns raised1

Failure to email endoscopy discharge summaries to GP practices

Concerns raised1

Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

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

Concerns raised1

Failure of mental health and substance misuse services to share patient information

Concerns raised1

Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge

Concerns raised1

Inadequate communication and liaison between hospital and community care providers after discharge

Concerns raised1

Failure to communicate relevant clinical information between hospitals

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

Concerns raised1

Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers

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

Actions described in response 1

Actions described in response 5

Respondent positions 1

Actions described in response 4

Actions described in response 3