Recurring concern

Unreliable authorisation and documentation of departures from clinical plans and standards

Get email alerts

Request correction

First reported 9 Oct 2015•Latest report 25 Apr 2024

Definition

What this concern includes

Includes failures to recognise, justify, document, authorise or review departures from a patient's management plan, recognised clinical pathway or best-practice timeframe when the departure is clinically significant and requires accountable oversight.

Not included

Excludes ordinary clinical variation or justified deviation where the rationale and appropriate authorisation are reliably documented.
Excludes generic clinical-record, staffing or communication deficiencies that are not directly tied to a clinically significant departure from an established plan or standard.
Excludes failures to follow a plan or standard where no departure, exception or deviation is identified.
Excludes failures occurring after a departure has been appropriately authorised and documented, including separate treatment, monitoring or escalation failures.

Reports: 3
Individual concerns: 4
Date range: 2015–2024
Stated actions: 2

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.

North Tyneside General Hospital1

Tameside and Glossop Integrated Care NHS Foundation Trust1

United Children's Services Limited1

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 Apr2024
Leicester City and South Leicestershire
Concerns raised1
1. Lack of documentation explaining or justifying care plan deviations
This report raised 11 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

Ash BANNISTER · 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

Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of documentation explaining or justifying care plan deviations
Wider context from the report
“I heard evidence to confirm there was no documentation created by United Children’s Services to detail the date on which Ash’s Ligature Risk Assessment was deemed to be no longer required or to explain the rationale behind the making of that decision. There is no documentation to explain or justify the deviation from Ash’s care plan on the morning that Ash died. Further, the Court heard evidence to confirm that there was little or no communication of Ash’s historic Child Sexual Exploitation risk between the two United Children’s Services care homes when Ash moved from The Oaks to The Laurels in July 2020. Lack of documentation and poor communication is a concern. ”
Source location
Ash BANNISTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Dec2019
Manchester South
Concerns raised2
1. Lack of a system requiring suitably experienced clinician agreement for departures from recognised best practice timescales
2. Failure to record the rationale for departing from recognised best practice timescales
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

Shirley Anne Nightingale · 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

Shirley Anne Nightingale died at Tameside General Hospital on 20 May 2019 after a catastrophic gastrointestinal bleed. The report identified concerns about the lack of clear systems for prioritising urgent endoscopies, following up requests, and recording or authorising departures from recommended timescales.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system requiring suitably experienced clinician agreement for departures from recognised best practice timescales
Wider context from the report
“3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision. ”
Source location
Shirley Anne Nightingale · 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 rationale for departing from recognised best practice timescales
Wider context from the report
“3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision. ”
Source location
Shirley Anne Nightingale · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Oct2015
Newcastle upon Tyne
Concerns raised1
1. Failure to follow or explain departures from a patient's management plan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Conduct monthly spot audits of surgical-ward patients’ management plans, documentation and observation compliance.
  Stated by Northumbria Healthcare NHS Foundation TrustStated completed
2. Action
  Run daily ward-round safety huddles using the STOP system to review high NEWS scores, concerns and management plans, including critical-care escalation.
  Stated by Northumbria Healthcare NHS Foundation TrustStated completed
AI-generated summary

Patrick Joseph Carrick · 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

Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.

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 follow or explain departures from a patient's management plan
Wider context from the report
“(1) There was a significant departure from a patients management plan without explanation (2) The above was compounded as it occurred in a period of rapid deterioration (3) Crucial blood analysis results were not actioned (4) Inadequate completion of nursing and medical notes ”
Source location
Patrick Joseph Carrick · 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 monthly spot audits of surgical-ward patients’ management plans, documentation and observation compliance.

Verbatim wording from the response
“All staff are aware of the importance of following a management plan. In order to check if management plans are being followed Matrons carry out monthly spot audits on a minimum of 5 patients on all surgical wards across the Trust. These audits check if documentation is being completed correctly, such as NEWS, fluid and urine output charts, and will identify if management plans are not being followed; such as observations not being carried out within the agreed timeframe.”

Source location
2015-0374-Response-by-Northumbria-Health-Care-NHS-Trust
Page 1 · response
Published 9 October 2015
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
Run daily ward-round safety huddles using the STOP system to review high NEWS scores, concerns and management plans, including critical-care escalation.

Verbatim wording from the response
“In addition to the above, the Trust now runs daily safety huddles on ward rounds that include a "STOP" system where patients with a high NEWS score or a particular concern are discussed and management plans are reviewed. This includes a discussion as to whether there is a need to involve others such as critical care.”

Source location
2015-0374-Response-by-Northumbria-Health-Care-NHS-Trust
Page 2 · response
Published 9 October 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of documentation explaining or justifying care plan deviations

Concerns raised2

Lack of a system requiring suitably experienced clinician agreement for departures from recognised best practice timescales

Failure to record the rationale for departing from recognised best practice timescales

Concerns raised1

Failure to follow or explain departures from a patient's management plan

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

Actions described in response 2