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.

11 Jul2021
Mid Kent and Medway
Concerns raised1
1. Failure to share all relevant information between Child and Adult Mental Health Teams for risk assessment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Appropriate information was shared; the psychiatrist could not disclose the second incident because it was not known.
  Stated by North East London NHS Foundation TrustDisputes the concern
AI-generated summary

ELEANOR ROSE MURPHY-RICHARDS · 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

Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.

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 between Child and Adult Mental Health Teams for risk assessment
Wider context from the report
“(3) Not all relevant information was shared between the Child & Adult Mental Health Team about the circumstances disclosed of events on the night of 29ᵗʰ September of Ellis’s failed attempt at hanging as part of a risk assessment. ”
Source location
ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report
Page 2 · 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
Appropriate information was shared; the psychiatrist could not disclose the second incident because it was not known.

Verbatim wording from the response
“It is my understanding that the psychiatrist contacted the care coordinator after the telephone assessment of Ellis. The psychiatrist shared the information that was available to them at the time. The psychiatrist informed the care coordinator about the incident the previous night involving a ligature. The psychiatrist was not aware at that time of the second incident at the Youth Club. The psychiatrist also discussed their assessment of Ellis’ suicide risk. They explained to the care coordinator that Ellis did not want to talk to them about the incident, which impacted on the ability to risk assess and establish if there were ongoing suicidal thoughts, intent or plans.”

Source location
2021-0237-Response-from-Trust-Head-Office_Published
Page 4 · response
Published 15 July 2021
Open published response
28 Jun2021
Essex
Concerns raised1
1. Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records
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

Fiona May Humberstone · 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

Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

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 primary and secondary care systems to provide timely access to definitive medication and concordance records
Wider context from the report
“(2) Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as electronic systems were presently configured, readily access information held by GP practices regarding individual patients (and vice versa). It appeared that this evidence was provided by way of an explanation as to why accurate and up to date medication/prescribing information was not routinely obtained by clinicians in advance of reviews of patients. Absent any other system for ensuring swift and accurate information transfer between primary and secondary care providers, then the continuation of a state of affairs where a consultant psychiatrist is undertaking a review of a mental health patient but does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication) gives rise to a conspicuous risk of future deaths. The EPUT witness suggested that this was a matter for the Clinical Commissioning Group (CCG) to address. ”
Source location
Fiona May Humberstone · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Mar2021
Liverpool and the Wirral
Concerns raised2
1. Failure to transmit discharge summaries to GP practices
2. Failure to record the correct GP practice name and identifier on discharge summaries
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

Helen Margaret McLean · 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

Helen Margaret McLean was without Edoxaban from 5 November 2020 after medication and discharge information were not correctly transferred between hospital, GP practices and her nursing home. She was admitted to hospital with an ischaemic stroke on 18 November 2020 and died on 21 November 2020; the report found it more likely than not that Edoxaban may have prevented the fatal event. A substantive concern was that the discharge summary was not received by the GP practice and contained an incorrect GP practice identifier, with medication-transfer processes also failing to identify the omission.

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 transmit discharge summaries to GP practices
Wider context from the report
“Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition. ”
Source location
Helen Margaret McLean · 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 record the correct GP practice name and identifier on discharge summaries
Wider context from the report
“Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition. ”
Source location
Helen Margaret McLean · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Jan2021
Manchester City
Concerns raised1
1. Delays in transmitting discharge letters when timely GP involvement is required
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

Norma Bradbury · 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

Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in transmitting discharge letters when timely GP involvement is required
Wider context from the report
“Mrs Bradbury was discharged on 22.02.19. The discharge letter to her GP instructed a review within 1 week to check Mrs Bradbury’s bloods and blood pressure, and to restart Losartan, and titrate the dose to her blood pressure. The consultant giving evidence at the hearing was clear that he expected this to have commenced within a week of discharge. The evidence of Mrs Bradbury’s GP was that the discharge letter was not received until 25.02.19. The GP also advised that the delay in receiving discharge letters was very variable, between days and weeks. I accept that in many cases the discharge letter is no more than a summary of an attendance and requires little or no further action on the part of the GP and the delay is of no consequence. However, where, as here, the discharging hospital requires GP involvement within 1 week of discharge a delay of 3 days in requesting or advising that involvement is not acceptable. While it was not possible to determine any difference in outcome in Mrs Bradbury’s case there is a risk that such a delay would make a difference. ”
Source location
Norma Bradbury · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Nov2020
North East Kent
Concerns raised1
1. Failure of communication and sharing of relevant information between treatment services
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.
Respondent positions 1
1. Position
  The site's planned decommissioning had no impact on patient care, communications or referral information because key staff remained in place.
  Stated by Ministry of DefenceDisputes the concern
AI-generated summary

PAUL HILLS · 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

Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of communication and sharing of relevant information between treatment services
Wider context from the report
“6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information. ”
Source location
PAUL HILLS · Prevention of Future Deaths report
Page 2 · 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 site's planned decommissioning had no impact on patient care, communications or referral information because key staff remained in place.

Verbatim wording from the response
“I note your concern, but I hope I can rectify any misunderstanding created at the Inquest about the planned closure of RAF Manston. Department of Community Mental Health clinicians were aware that the Defence Fire Training Development Centre Manston¹ was being decommissioned. Some confusion may have arisen about the gap between the MOD-wide announcement of the planned closure of the site and the planned decommissioning date itself. The decommissioning of the Centre did not begin until November 2020. Before and during April 2020 the Centre was still carrying out its assigned training tasks and all key staff remained in place. There was no impact on any patient care as a result of the planned decommissioning of the Manston base.”

Source location
2020-0247-Response-from-MP-MOD-Redacted.pdf
Page 5 · response
Published 29 December 2020
Open published response
15 Oct2020
Essex
Concerns raised1
1. Failure to enable relevant mental health teams to access and share important information
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement an interoperable health information exchange providing clinicians access to patient data across recording systems.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Use the health information exchange to share information across organisations through the shared care record for Essex STPs.
  Stated by Essex Partnership University NHS Foundation TrustStated planned
AI-generated summary

THOMAS JEFFERY KING · 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

Thomas Jeffery King was found hanging at his home on 28 April 2020, and his death was confirmed at the scene. The inquest concluded that he had intentionally ended his own life while experiencing very low mood and a history of poor mental health. The principal concern was that the Health and Justice Team used software that could not be accessed by other relevant mental health teams, meaning important information about crises and risks could be unavailable when assessing and managing a person.

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 enable relevant mental health teams to access and share important information
Wider context from the report
“(1) It was the evidence of the author of the EPUT Root Cause Analysis Investigation Report, ████████, that whilst all the other EPUT teams that came into contact with Mr King, such as the Mental Health Liaison Team and the Street Triage Team, used the same software called Mobius with which to record, access and share important information and developments regarding Mr King, one Team, namely the Health and Justice Team did not use this software and instead used software that was incapable of being accessed by the other teams. A consequence of this was that the other teams were wholly unaware of crises and other important information regarding Mr King’s mental health that were known to the Health and Justice Team. (2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture. (3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution. ”
Source location
THOMAS JEFFERY KING · 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 an interoperable health information exchange providing clinicians access to patient data across recording systems.

Verbatim wording from the response
“The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.”

Source location
2020-0207-Response-from-EPUT_Redacted.pdf
Page 1 · response
Published 3 December 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the health information exchange to share information across organisations through the shared care record for Essex STPs.

Verbatim wording from the response
“The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.”

Source location
2020-0207-Response-from-EPUT_Redacted.pdf
Page 1 · response
Published 3 December 2020
Open published response
26 Jun2020
Inner South London
Concerns raised1
1. Inadequate discharge plan communicated to GP
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.
Actions described in response 1
1. Action
  Require primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.
  Stated by Oxleas NHS Foundation TrustStated completed
AI-generated summary

Gary Etherington · 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

Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.

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 discharge plan communicated to GP
Wider context from the report
“The coroner found that there were two failures in medical care, namely 1. The failure to contact ████████ at the Mental Health Act assessment in April 2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP. ”
Source location
Gary Etherington · 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
Require primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.

Verbatim wording from the response
“Turning to your second concern that Mr Etherington was discharged without adequate consideration of his symptoms and communication to his general practitioner, I have ensured that all our primary care teams (PCP), who are the gateway to our secondary mental health services, write comprehensive letters to general practitioners addressing the specific issues raised by the general practitioner including outlining the outcome of assessments and treatment advice.”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 2020
Open published response
12 Mar2020
Manchester North
Concerns raised1
1. Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.
  Stated by Greater Manchester PoliceStated in progress
2. Action
  Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.
  Stated by Greater Manchester PoliceStated planned
3. Action
  Develop and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.
  Stated by Greater Manchester PoliceStated in progress
1. Action
  Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.
  Stated by North West Ambulance Service NHS TrustStated in progress
2. Action
  Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.
  Stated by North West Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.
  Stated by North West Ambulance Service NHS TrustRedirects responsibility
AI-generated summary

Jason Pendlebury · 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

Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and risk.

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 relevant prior mental-health contacts and assessments between GMP and NWAS
Wider context from the report
“I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital. It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take. I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services. A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made. The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels. ”
Source location
Jason Pendlebury · 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
Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.

Verbatim wording from the response
“One aspect of our ongoing IT Change Programme is the feasibility of an electronic Force to Force data exchange, which could potentially be used to share data electronically with agencies such as NWAS. It is anticipated that these advances in technology would improve the quality and efficiency of information sharing and is subject to ongoing review.”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 2 · response
Published 8 April 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.

Verbatim wording from the response
“GMP’s Public Service Reform leads, Chief Supt. ████████ and DCI ████████ are to consider the effectiveness of the current arrangements regarding this type of information sharing with partners and the Greater Manchester Health and Justice Board will be briefed on the concerns raised here (additional information on this body is included in the Summary below).”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 3 · response
Published 8 April 2020
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 implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.

Verbatim wording from the response
“In 2019 The Greater Manchester Health and Justice Board oversaw work to develop and implement a common approach to people in mental health crisis. The involved a working group, Health and Justice Task and Finish Group, which included senior representatives form GMP and the North-West Ambulance Service, in addition to the mental health trusts serving Greater Manchester, local authority approved mental health practitioners and Greater Manchester Combined Authority.”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 5 · response
Published 8 April 2020
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
Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.

Verbatim wording from the response
“The Trust jointly chaired a task and finish group with GMP, which was set up last year in response to a Regulation 28 report issued by Ms Joanne Kearsley in December 2018 to Greater Manchester Health and Social Care Partnership, Greater Manchester Combined Authority, Greater Manchester Police, North West Ambulance Service and Pennine Care NHS Foundation Trust. It was agreed that enhancements to the response around concern for welfare, and particularly risk to life, must be applied on a pan-GM basis, therefore Greater Manchester Mental Health NHS Foundation Trust and North West Boroughs Healthcare NHS Foundation Trust are also partners, despite not being involved in the specific case in question.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 2 · response
Published 8 April 2020
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
Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.

Verbatim wording from the response
“The task and finish group has drawn together a pan-GM protocol for responding to ‘risk to life’ where it presents as a result of mental health to blue light services to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk and to promote communication and escalation at the first point that a common understanding may falter.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 2 · response
Published 8 April 2020
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
Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.

Verbatim wording from the response
“When an NWAS mental health nurse carries out a telephone assessment, they would only be aware of a previous assessment by GMP or previous calls to GMP if this is communicated to NWAS by the police and documented by the call taker. GMP, and indeed any police force or emergency service, would be expected to share any information they felt to be pertinent. Once a clinician has completed an assessment, or returned the incident to dispatch if unable to carry out a triage, NWAS would not be made aware of any further updates from GMP as the clinicians no longer have sight of the incident.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 1 · response
Published 8 April 2020
Open published response
2 Mar2020
Hampshire (Central)
Concerns raised1
1. Poor communication between departmental services
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Share case learning through learning events, team meetings and joint training for Talking Therapies and CPE staff.
  Stated by Berkshire Healthcare NHS Foundation TrustStated completed
2. Action
  Develop shared mechanisms for recording referrals and risk information and escalating cases to CPE.
  Stated by Berkshire Healthcare NHS Foundation TrustStated in progress
AI-generated summary

Sophie Hannah May Boothe · 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

Sophie Hannah May Boothe had a history of mental health issues and died in a hotel in Hook on 19 June 2019 after an overdose and subsequent contact with mental health services. Concerns were raised that information about her treatment in Australia was not properly reviewed or understood, contributing to the downgrading of her urgent referral, and that poor communication between services led to missed opportunities for assessment and intervention.

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
Poor communication between departmental services
Wider context from the report
“It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie’s referral; this includes both the discharge summary and Sophie’s own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie’s referral. It became clear in evidence that the UK services did not understand that “Scheduled” is the Australian equivalent of being “Sectioned” and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE. Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie’s full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur. ”
Source location
Sophie Hannah May Boothe · 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
Share case learning through learning events, team meetings and joint training for Talking Therapies and CPE staff.

Verbatim wording from the response
“The learning from this case has been explored and discussed in a learning event and also in team meetings to ensure the team are consistent in terms of decision making relating to triaging.”

Source location
2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
Page 5 · response
Published 1 October 2020
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 shared mechanisms for recording referrals and risk information and escalating cases to CPE.

Verbatim wording from the response
“Notwithstanding these immediate changes and the significant learning embedded following Sophie’s death, the transformation of the Trust’s wellbeing services is a much larger piece of work with changes that are designed to ensure that missed opportunities to share such referral information are minimised as far as is possible. Ongoing work within Talking Therapies will focus on clear shared mechanisms for recording referrals, risk information and escalating to the CPE.”

Source location
2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
Page 6 · response
Published 1 October 2020
Open published response
28 Feb2020
Manchester West
Concerns raised1
1. Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment
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

Irene Whittingham · 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

Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.

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 community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment
Wider context from the report
“1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines. ”
Source location
Irene Whittingham · 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 share all relevant information between Child and Adult Mental Health Teams for risk assessment

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 primary and secondary care systems to provide timely access to definitive medication and concordance records

Concerns raised2

Failure to transmit discharge summaries to GP practices

Failure to record the correct GP practice name and identifier on discharge summaries

Concerns raised1

Delays in transmitting discharge letters when timely GP involvement is required

Concerns raised1

Failure of communication and sharing of relevant information between treatment services

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

Concerns raised1

Failure to enable relevant mental health teams to access and share important information

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

Concerns raised1

Inadequate discharge plan communicated to GP

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 raised1

Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS

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

Poor communication between departmental services

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

Respondent positions 1

Respondent positions 1

Actions described in response 2

Actions described in response 1

Actions described in response 5

Respondent positions 1

Actions described in response 2