Recurring concern

Failure to escalate patient issues to multidisciplinary review

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First reported 5 Oct 2015•Latest report 8 Feb 2022

Definition

What this concern includes

Includes failures to recognise, initiate, document or complete escalation of material patient issues, incidents or concerns to a multidisciplinary clinical or care-planning review where the purpose is to reassess risks, care needs or protective arrangements; include escalation by Care Coordinators and comparable care functions.

Not included

  • Excludes generic communication, supervision or escalation deficiencies where no patient issue is being escalated to multidisciplinary review.
  • Excludes failures in the quality, attendance or conduct of a multidisciplinary meeting after the issue was reliably escalated.
  • Excludes escalation to emergency, safeguarding, complaint or regulatory processes where multidisciplinary patient review is not the shared control.
  • Excludes failures limited to updating care plans or risk assessments after a multidisciplinary review has taken place.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2022

First to latest report issue date

Stated actions
4

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 of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
Nant-y-Gaer Hall Nursing Home1
NHS England1
North East London NHS Foundation Trust1
Pentree Lodge1

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. Essex

    AI-generated summary

    John David Moore · 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

    John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.

    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 recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors

    Wider context from the report

    “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role: (i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death; (ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all; (iii) inadequate communication with other primary and secondary care providers; (iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients; (v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors. ”

    Source location

    John David Moore · 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

    Implement the MaST caseload-management tool through agreed pilot sites to support risk, disengagement, caseload, and record-keeping oversight.

    Verbatim wording from the response

    “The Trust is in the process of gathering data in order to implement the Management and Supervision Tool (MaST) caseload management tool, which will help the care coordinator to”

    Source location

    Response from Essex Partnership NHS Trust
    Page 3 · response
    Published 17 April 2026

    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

    Not all patients require weekly MDT discussion; professional judgment, dynamic risk assessment and other discussion routes are considered sufficient.

    Verbatim wording from the response

    “It is within a professional’s role to determine whether a patient’s care would need to be presented to the MDT meeting and this is based on clinical judgement. A care coordinator is a registered professional who would work within their code of conduct, which provides a clear framework for accountability and responsibility, and the Trust values. Care coordinators would have undertaken Trust induction and training in order to support their role and would be deemed to be equipped to independently make clinical decisions around presentation to MDT. Their decision would be based upon dynamic risk assessment of the patient, the therapeutic relationship they have with the patient and their family, and their identified needs. Not all patients on caseloads would require discussion at the weekly MDT meeting as there are other means of formulating discussions to meet the needs of the patient.”

    Source location

    Response from Essex Partnership NHS Trust
    Page 4 · response
    Published 17 April 2026

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Dylan Jay Henty · 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

    Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.

    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

    Unclear escalation of absconding incidents to MDT review

    Wider context from the report

    “iv. There appeared to have been inconsistency in the reporting of incidents of absconding. You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC. Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level, for example, to consider whether current residential arrangements continue to be appropriate. ”

    Source location

    Dylan Jay Henty · 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

    Inform the multidisciplinary team or make referrals after absconding incidents and conduct six-weekly or more frequent monitoring visits with placement review where needed.

    Verbatim wording from the response

    “6. Dependent on the level and frequency of absontion the intention and the risk. The appropriate placement of the home would be assessed. The MDT would immediately be informed in the event of any absobtion, if there are relevant teams in place, if not a referral is made. Reviews and monitoring visits take place 6 weekly or more frequent if needed by the care home. The placement of the home is reviewed in these visits if needed and where appropriate.”

    Source location

    2019-0334-Response-by-Pentree-Lodge-Care-Home
    Page 2 · response
    Published 10 November 2019

    Open published response

  3. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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 escalate family reports of changes in presentation for multidisciplinary review

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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

    Ensure AABIT staff are competent in risk assessment and escalation of risk.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  4. North Wales (East and Central)

    AI-generated summary

    Peter Scott · 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 Scott, who had frontal lobe dementia and lived in a nursing home, died after choking on a latex glove; two further gloves were found in his stomach. The care home acknowledged that its systems did not document a process for escalating incidents or concerns to a multidisciplinary meeting to review risk assessments and care plans.

    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 documented process for escalating incidents or concerns to multidisciplinary review of risk assessments and care plans

    Wider context from the report

    “The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated so as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care. ”

    Source location

    Peter Scott · 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 and continue evaluating the alert and incident process for changes in residents’ physical conditions and behaviour, including escalation, handovers, follow-up and reporting files.

    Verbatim wording from the response

    “In order to fully comply with the regulation 28 we have addressed our alert system. This will alert all staff to changes in our residents’ physical conditions and their behaviours. The new system is self-explanatory (please see copy’s sent - initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in charge and is escalated by the nurse (please see copies sent). This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not. All staff have undergone a training session and undergone a supervision session on the changes.”

    Source location

    2015-0398-Response-by-Nant-Y-Gaer-Hall
    Page 1 · response
    Published 5 October 2015

    Open published response
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Data last updated 7 September 2026