Recurring concern

Failure to ensure timely specialist dermatology input for acute severe skin conditions

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First reported 3 Dec 2021•Latest report 13 Oct 2023

Definition

What this concern includes

Includes failures of the dedicated specialist dermatology pathway for acute severe skin conditions, including timely consultation or advice, biopsy where clinically required, ongoing inpatient consultant oversight, referral and access arrangements, commissioning coverage, and coordination of specialist dermatology care.

Not included

  • Excludes generic clinical staffing, training, communication or commissioning deficiencies unless they directly impair specialist dermatology input for an acute severe skin condition.
  • Excludes dermatology conditions or routine dermatology referrals where acute severity or the need for specialist safety-critical input is not identified.
  • Excludes failures limited to general consultant review or specialist input outside dermatology.
  • Excludes clinical management failures occurring after appropriate specialist dermatology input has been obtained when no dermatology-access or oversight deficiency is identified.
Reports
3

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2021–2023

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Work and Pensions1
Department of Health and Social Care1
Kent and Medway Mental Health NHS Trust1
Maidstone and Tunbridge Wells NHS Trust1
North Cumbria Integrated Care NHS Foundation Trust1

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.

  1. North London

    AI-generated summary

    Peter Carr · 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

    Peter Carr developed a severe rash and was admitted to North Middlesex Hospital, where he was later found to have a drug reaction consistent with Stevens-Johnson Syndrome. The principal concern was that patients with acute, severe skin conditions may not receive consultant dermatology input, timely biopsy, and ongoing dermatological oversight during an inpatient stay.

    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 ongoing consultant dermatology oversight during inpatient stays

    Wider context from the report

    “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay. ”

    Source location

    Peter Carr · 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

    Lack of biopsy within 24 hours for acute severe skin conditions

    Wider context from the report

    “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay. ”

    Source location

    Peter Carr · 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

    Lack of consultant dermatology input within 24 hours for acute severe skin conditions

    Wider context from the report

    “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay. ”

    Source location

    Peter Carr · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Cumbria

    AI-generated summary

    Gordon Bernard Hendley · 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

    Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

    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 obtain dermatology advice for suspected Stevens-Johnson Syndrome

    Wider context from the report

    “1) Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate (perhaps over 10% in a man of Gordon’s age and frailty), he was referred with this diagnosis by an experienced GP. While evidence suggests a medical consultant was contacted he did not see Gordon himself and I heard no evidence to suggest a dermatologist was consulted for advice. Also the SCORTEN or ABCD-10 prognostic tools were not used, they may have been helpful. ”

    Source location

    Gordon Bernard Hendley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Mid Kent and Medway

    AI-generated summary

    TERENCE TALBOT · 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

    Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

    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 specialist dermatology review for severe exfoliative dermatitis

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”

    Source location

    TERENCE TALBOT · 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

    Nominate a lead clinician to review and clarify urgent and non-urgent dermatology referral pathways.

    Verbatim wording from the response

    “With regards to referral pathways and specialty dermatology referrals, the Trust’s Clinical Director for specialist medical services has been asked to nominate a lead clinician to review the pathway into”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 1 · response
    Published 16 December 2021

    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

    Scope whether to include or contract external dermatology services within the current pathway.

    Verbatim wording from the response

    “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    Commission additional staff training on available dermatology services, referral pathways and support systems.

    Verbatim wording from the response

    “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    The Trust does not itself provide dermatology services, limiting its direct responsibility for specialist dermatology referral.

    Verbatim wording from the response

    “Response Awareness and escalation techniques form part of training that is delivered to nursing colleagues. As identified within the hearing, the Trust, (albeit not in a timely manner), did obtain community dermatology opinion and support (the Court will recall that the Trust does not provide dermatology services itself).”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 1 · response
    Published 16 December 2021

    Open published response
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Data last updated 7 September 2026