Recurring concern

Failure to keep historical risk information accessible for later risk assessment

First to latest report 2 Nov 2015 — 21 May 2024

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
9

What this concern includes

Includes failures to record, structure, display, maintain or retrieve historical, static or contextual risk information in a form that staff can readily access and use during later safety or dynamic risk assessment, including offender-risk records and comparable safety-risk records.

What is not included
  • Excludes failures to perform a risk assessment when relevant historical information was accessible and the assessment process itself was deficient.
  • Excludes generic clinical, care or administrative record-keeping failures where historical or contextual risk information is not the material object.
  • Excludes failures limited to sharing risk information between organisations after it was reliably recorded and accessible.
  • Excludes hazard-specific or system-specific risk-information controls, such as PNC or NOMIS, when that named system supplies the more specific supported boundary.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Tracy Frances MCCARTHY · 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

    Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.

    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 record acknowledged amitriptyline risks in an accessible way for all practitioners

    Wider context from the report

    “(3) Ms McCarthy’s Amitriptyline prescriptions had previously been issued on a daily basis, to mitigate the risk of overdose. However, following her admission to hospital (mentioned above) a GP at The Tredegar Practice took the decision to reduce the dose slightly, but transfer to monthly prescriptions, thereby allowing Ms McCarthy access to 28 days’ worth of Amitriptyline all at once. A GP from The Tredegar Practice told me that they thought this was “risky” but said that the GP who made that decision was not familiar with the patient and maybe wouldn’t have known the rationale for daily prescriptions. They also told me that the Practice was probably “over-reliant on the knowledge of particular doctors that treated her.” The concern is that too great an emphasis was placed on the knowledge of a few individuals, which led to acknowledged risks not being put in the records in a way that would alert any practitioner to them. ”

    Source location

    Tracy Frances MCCARTHY · 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

    Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.

    Verbatim wording from the response

    “2. Identification of patients to be entered into the framework.”

    Source location

    Response from The GP Partners
    Page 2 · response
    Published 23 May 2024

    Open published response

  2. Berkshire

    AI-generated summary

    Paula Elizabeth ELSLEY · 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

    Paula Elizabeth ELSLEY was found unresponsive at home on 28 March 2022 and declared deceased. The inquest concluded that she was suffering from undiagnosed lung cancer with a metastatic brain tumour, which led to an abscess that caused her death. Concerns included smoking status not being readily accessible in GP records and NICE guidance on chest X-ray referral thresholds not being routinely considered or formally embedded in practice.

    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 record and highlight patients' current or former smoking status in an immediately accessible manner

    Wider context from the report

    “1. Smoking status During the inquest I heard evidence that a patient's smoking status (current or former) was not routinely recorded by the GP practice in a manner that was immediately accessible when reviewing the medical records. I heard that it may be necessary to search through consultation notes and other records to discover this information and GPs do not necessarily have time to do so. A patient's current or former smoking status is relevant information for a GP considering whether a chest x-ray ought to be considered in line with NICE guideline entitled 'Suspected cancer: recognition and referral' (NG12). The GPs who gave evidence agreed that it would be helpful if this information was flagged and the GP practice has indicated that it intends to introduce such a system. However this is not yet in place and I am concerned that the risk of this information not being highlighted remains a current risk. ”

    Source location

    Paula Elizabeth ELSLEY · 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

    Clarified how clinicians should check and document smoking status using the patient care history during consultations.

    Verbatim wording from the response

    “Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page).”

    Source location

    Response from Ringmead Medical Group
    Page 1 · response
    Published 4 July 2024

    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

    Immediate visibility of smoking status when opening patient notes was not feasible because of IT issues affecting more than 42,000 patients.

    Verbatim wording from the response

    “Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page).”

    Source location

    Response from Ringmead Medical Group
    Page 1 · response
    Published 4 July 2024

    Open published response

  3. Derby and Derbyshire

    AI-generated summary

    Terri Liz Harris and 3 others · 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

    Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.

    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 maintain accurate, prominent and readily updateable offender risk records

    Wider context from the report

    “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making, and indeed was not read at key and critical points. Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed. The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners. ”

    Source location

    Terri Liz Harris and 3 others · 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

    Develop and roll out a new assessment service presenting relevant risk information in an updateable, practitioner-focused interface.

    Verbatim wording from the response

    “A new assessment service is in development and aims to present relevant information about risk, needs and strengths back to the practitioner to draw together threads and support holistic and high-”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 29 November 2023

    Open published response

  4. South Wales Central

    AI-generated summary

    Samuel Joseph Gomm · 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

    Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.

    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 the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments

    Wider context from the report

    “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk. (3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam. (4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place. (5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm ”

    Source location

    Samuel Joseph Gomm · 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

    Improve inpatient staff WCCIS access and training so staff can complete risk documentation without duplicate Word templates.

    Verbatim wording from the response

    “2. As Powys Teaching Health Board inpatient staff are currently only able to read information stored on the Welsh Community Care Information System for case recordings, they have relied on a Welsh Applied Risk Research Network Word Document. This is then uploaded and attached to Welsh Community Care Information System by admin staff. It is accepted that this has led to a duplication of work and the risk of important information being lost. Having identified this, Powys Teaching Health Board are updating training and access arrangements for inpatient staff required to complete the Welsh Applied Risk Research Network document. This will ensure that all Welsh Applied Risk Research Network document will be recorded on the Welsh Community Care Information System and there will no longer be a need to use the Word Document template.”

    Source location

    Response from Powys County Council and Powys Teaching Health Board
    Page 2 · response
    Published 16 September 2022

    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

    Update WCCIS to record risk chronologies and significant self-harm events, supporting dynamic reassessment.

    Verbatim wording from the response

    “16. This would include but is not limited to events such as, relationship breakdown, loss of care, increase in substance use, increase in contact with services, particularly out of hours. All significant self-harming events should be recorded on the document, this includes disclosure of thoughts of self harm. To support this WCCIS will be updated to include a Chronology of events to enable workers to keep a succinct and easily accessible record. This will allow staff to easily identify if there has been a recordable event, creating a clear timeline of presenting risks. This will alert practitioners to any changes or patterns of behaviour and enable better dynamic risk assessing.”

    Source location

    Response from Powys County Council and Powys Teaching Health Board
    Page 6 · response
    Published 16 September 2022

    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

    Continue six-monthly Welsh Applied Risk Research Network record audits by Powys Teaching Health Board.

    Verbatim wording from the response

    “22. In October 2021 and April 2022 Powys Teaching Health Board undertook an internal audit of Welsh Applied Risk Research Network documentation. Compliance with reviews and the quality of content was rated as good. Powys Teaching Health Board will continue to audit Service User records on a 6 monthly basis.”

    Source location

    Response from Powys County Council and Powys Teaching Health Board
    Page 7 · response
    Published 16 September 2022

    Open published response

  5. Suffolk

    AI-generated summary

    LEVI CRONIN · 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

    Levi Cronin, a serving prisoner at HMP Highpoint, was found hanging in a shower and later confirmed deceased at West Suffolk Hospital. The inquest recorded a conclusion of suicide and identified concerns about insufficient recording and information-sharing, inadequate staffing, and inadequate support and supervision within the mental health department and prison staff.

    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 record static or historical risk information in a readily accessible form

    Wider context from the report

    “- The recording of ‘Static’ or ‘historical’ risk information (on a need to know basis) in a form that would make it more readily accessible to those at a later stage who might have to assess a changing situation and make a new dynamic risk assessment following a recent ‘trigger’ event ”

    Source location

    LEVI CRONIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Cumbria

    AI-generated summary

    Richard Scott Green · 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

    Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.

    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 SystmOne to provide usable search and clear flagging of important historical information

    Wider context from the report

    “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”

    Source location

    Richard Scott Green · 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

    Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 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

    Implement an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 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

    Provide full training and regular training updates for the new electronic healthcare system.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026