Recurring concern

Failure to obtain relevant collateral information from family and social supports

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First reported 10 Jan 2014•Latest report 5 Mar 2026

Definition

What this concern includes

Includes failures to identify, seek, obtain or use relevant collateral information from family, carers, social workers or other directly involved social supports when that information is material to patient assessment, risk management, support or care.

Not included

  • Excludes generic failures to gather information when no family or social-support collateral is involved.
  • Excludes failures concerning continuity of care, handover or referral unless the material deficiency is specifically failure to obtain or use collateral information from family or social supports.
  • Excludes unrelated failures to provide familial support or to balance confidentiality with family involvement where no failure to obtain relevant collateral information is asserted.
  • Excludes clinical-record retrieval or genetic-history investigation unless the report specifically frames it as collateral information from family or social supports.
Reports
37

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
72

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.

NHS England7
Department of Health and Social Care3
East London NHS Foundation Trust3
Metropolitan Police Service3
Ministry of Justice3
Essex Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North East London NHS Foundation Trust2
North London NHS Foundation Trust2
Recipient name withheld2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Browning Street Surgery1
Care Quality Commission1
Cornwall Partnership NHS Foundation Trust1
Cumbria, Northumberland, Tyne and Wear 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. East London

    AI-generated summary

    Caroline Adeyelu · 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

    Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.

    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 information gathering from wider family members

    Wider context from the report

    “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided. ”

    Source location

    Caroline Adeyelu · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Michaela FINCH · 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

    Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based 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 to communicate family concerns to assessing clinicians

    Wider context from the report

    “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal. ”

    Source location

    Michaela FINCH · 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

    Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.

    Verbatim wording from the response

    “The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan.”

    Source location

    2026-0064 - Response from Greater Manchester Mental Health
    Page 2 · response
    Published 11 February 2026

    Open published response

  3. Inner South London

    AI-generated summary

    Simon Moss · 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

    Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.

    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 and use family contact details in mental health assessment and discharge risk mitigation

    Wider context from the report

    “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on. However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account. That triage note was necessarily brief and so the detail in the EPCR was lost. Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent. Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services. Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted. The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means. The EPCR was accessible on systems available to the mental health nurse however. While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used, which could otherwise: (a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation, and (b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected). I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths. ”

    Source location

    Simon Moss · 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

    Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.

    Verbatim wording from the response

    “Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services.”

    Source location

    2026-0052 - Response from NHS England
    Page 1 · response
    Published 4 February 2026

    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

    Publish and implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.

    Verbatim wording from the response

    “The recently launched NHS England Staying safe from suicide guidance was co-produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/carers in gaining an overall understanding and need for safety planning.”

    Source location

    2026-0052 - Response from NHS England
    Page 1 · response
    Published 4 February 2026

    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

    Ensure next-of-kin details are added to patient information during triage at University Hospital London.

    Verbatim wording from the response

    “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.”

    Source location

    2026-0052 - Response from NHS England
    Page 2 · response
    Published 4 February 2026

    Open published response

  4. Essex

    AI-generated summary

    STUART CHRISTOPHER JAMES BERRY · 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

    STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

    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 communicate with families and gather collateral information

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”

    Source location

    STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  5. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Abigail Eleanor Ann Jelly · 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

    Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.

    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 demonstrate professional curiosity and obtain relevant information from family members

    Wider context from the report

    “Abigail was known to the community mental health services for just a few weeks. She had been living with her parents immediately before she died and they had attended medical appointments with her. Abigail’s parents were not spoken to by mental health professionals about their daughter’s circumstances when they would have been able to provide valuable information about her research into and planning around ending her life. It was accepted that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally and I am concerned that there is a risk of future deaths. ”

    Source location

    Abigail Eleanor Ann Jelly · 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

    Work with involved teams to improve professional curiosity when caring for patients.

    Verbatim wording from the response

    “There was also a lack of professional curiosity in working with Abigail, and this has been worked on with the teams involved.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 1 · response
    Published 14 October 2025

    Open published response

  6. Somerset

    AI-generated summary

    Edwin Everett Milne Price · 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

    Edwin Everett Milne Price, who lived in a nursing home and required hoisting for transfers, was admitted to hospital with diabetic ketoacidosis and fell out of bed the following day. He sustained a fractured humerus and a retroperitoneal bleed, which was recorded as the cause of his death. The principal concerns were that his falls risk assessment was not completed within 24 hours, relevant information was not obtained from the nursing home, and mitigation measures were not put in place.

    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 nursing home information for falls risk assessments when admitted patients are unable to communicate

    Wider context from the report

    “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward. 2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate. 3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed. 4. The lack of a risk assessment meant that mitigation measures were not in place. 5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death. 6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes. ”

    Source location

    Edwin Everett Milne Price · 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

    Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.

    Verbatim wording from the response

    “In response to this incident, our acute medical unit (AMU) has introduced a checklist to be completed on admission which involves contacting the patient’s family, care home or community hospital to gather more detailed information about the patient (see appendix 1). The guidance on the patient’s baseline function and the usual mitigations that are in place in their usual residence to reduce the risk of harm”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 2 · response
    Published 2 September 2025

    Open published response

  7. Cornwall and Isles of Scilly

    AI-generated summary

    Brian Ingram · 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

    Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

    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 include available family members in clerking patients with dementia

    Wider context from the report

    “2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history. ”

    Source location

    Brian Ingram · 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

    Require LML staff to involve relatives and carers throughout assessment and care, documenting and justifying any proportionate exclusion.

    Verbatim wording from the response

    “2.2 It was suggested in evidence at the inquest, that the practice of asking a family member to remain in the ambulance, may have been a remnant of procedure adopted during the COVID-19 pandemic. LML has reflected upon the decision of the ECA ambulance crew in this case, which was not in line with their policy. Following the inquest, LML has:”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    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

    Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.

    Verbatim wording from the response

    “2.3 Whilst CFT was not aware that Mr Ingram’s daughter was waiting in the ambulance in this case, we appreciate that had our Minor Injuries Unit (MIU) staff come to the ambulance to carry out an initial assessment of Mr Ingram and consider his suitability for review and/or treatment in the MIU, they would have discovered her waiting there, and had the opportunity to take any relevant history. It is established MIU practice to assess patients in the ambulance, prior to checking them in. This is expressly stated in the MIU Operational Policy, which sets out the procedure for patients being brought into the MIU by ambulance, as follows:”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 3 · response
    Published 14 October 2025

    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

    Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.

    Verbatim wording from the response

    “2.5 The facts relating to Mr Ingram’s inquest have also been used as a case study and presented at the Learning from Experience (LFE) Forum, a meeting attended by all MIU clinical leads, to discuss any collective issues to be addressed, and to share learning and best practice across CFT. It was reiterated at the LFE Forum, that in accordance with policy, all patient arrivals via ambulance should be initially assessed in the ambulance, and a full assessment of the patient should be carried out by an MIU clinician (discussed further below).”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 4 · response
    Published 14 October 2025

    Open published response

  8. Surrey

    AI-generated summary

    Rose Annie Harfleet · 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

    Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.

    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 routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities

    Wider context from the report

    “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children. ”

    Source location

    Rose Annie Harfleet · Prevention of Future Deaths report
    Page 3 · 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

    Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.

    Verbatim wording from the response

    “The Trust has a Learning Disabilities and/or Autism Policy to Support Children and Adults with Learning Disability and/or Autism. This has been developed in accordance with other national and local guidelines, including the Mental Capacity Act 2005, Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy (2021), NICE NG93 mental capacity, reasonable adjustments and quiet areas, NG11 restraint, Autism Spectrum Disorder in Adults; Diagnosis and Management – Clinical Guide CG142 (NICE 2016), NHS LD&A Programme 2025 Digital flagging and hospital passports and the Equality Act (2010). Specifically the Trust policy includes an emergency admission flow chart and information about supporting carers and engaging with them in decision making including care and interventions.”

    Source location

    Response from Royal Surrey County Hospital NHS Foundation Trust
    Page 1 · response
    Published 20 May 2025

    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 Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.

    Verbatim wording from the response

    “The Trust is not however aware of any specific national guidance on consultation with the parents and carers of children with profound disabilities although the Trust recognises that this is an essential part of good clinical practice. Whilst not specifically related to children with profound disabilities, the Trust is aware of Martha’s Rule, and have been selected to be part of Phase 2 for implementing this. Work has commenced to address the three metrics for delivery for adults and children.”

    Source location

    Response from Royal Surrey County Hospital NHS Foundation Trust
    Page 3 · response
    Published 20 May 2025

    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 rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.

    Verbatim wording from the response

    “To improve awareness of learning disability and autism within the health and social care system, under the Health and Care Act 2022, from 1 July 2022 Care Quality Commission (CQC) registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role. This will help to ensure that staff have the right knowledge and skills to provide safe and informed care. To support providers to meet the statutory training requirement, we have been rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce: this specifically highlights the difference that listening to parents can make.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 20 May 2025

    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

    Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.

    Verbatim wording from the response

    “As part of the government’s 10-year plan and transforming the NHS from analogue to digital, the government will create a more modern NHS by bringing together a single patient record, summarising patient health information, test results, and letters in one place, through the NHS App. It will put patients and their advocates in control of their own medical history, meaning they do not have to repeat it at every appointment, and that staff have the full picture of patients’ health.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 20 May 2025

    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

    Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.

    Verbatim wording from the response

    “RCPCH are actively supporting the role out of Martha’s Rule. Martha’s Rule is a patient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm.”

    Source location

    Response from Royal College of Paediatrics
    Page 2 · response
    Published 20 May 2025

    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

    Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.

    Verbatim wording from the response

    “In addition, RCPCH are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.”

    Source location

    Response from Royal College of Paediatrics
    Page 2 · response
    Published 20 May 2025

    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

    Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.

    Verbatim wording from the response

    “Speaking with and respecting patients’ families is a key aspect of the mandatory learning disability and autism training (aka the Oliver McGowan training) so all clinicians involved should be aware of this. A difficulty with regard to the implementation and regulation of providing this training has been the delay to the publication of the Code of Practice. This will give providers and CQC staff clearer guidance on the requirements of the training and for CQC to regulate. Interim guidance is available on our website.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 20 May 2025

    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

    Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.

    Verbatim wording from the response

    “1. The management of children with profound disabilities within a hospital setting In September 2024, the Royal College of Emergency Medicine (RCEM) published a Learning Disabilities Toolkit [1]. This resource includes information about how best to approach the management of people with a learning disability and suggestions on how to make reasonable adjustments in an ED setting. The toolkit also makes specific mention of intra-abdominal pathology and aspiration. The RCEM also provide additional online educational resources related to Learning Disabilities [2]. The RCEM feel it would not be appropriate to comment about the care delivered in the in-patient setting.”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 20 May 2025

    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

    Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.

    Verbatim wording from the response

    “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting The RCEM Learning Disability Toolkit [1] emphasises the importance of listening to family and carers of people with a learning disability in the ED. The RCEM are represented in the group developing the ED version of the national paediatric early warning system (nPEWS) with NHS England. A key component of the nPEWS (and the current draft of the emergency department specific nPEWS score - EDnPEWS) is parental/carer concern [3]. The response from the parent/carer is built into the escalation response. The RCEM is also supportive of the work just commencing via NHS England’s Patient Safety Collaborative, which is looking to test the use of Martha’s Rule in the ED setting. We would also note”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 20 May 2025

    Open published response

  9. Manchester North

    AI-generated summary

    Mark Anthony Fernandez · 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

    Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.

    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 take account of long-term carers' and social services' views and knowledge in best interest decisions

    Wider context from the report

    “1. The hospital passport was not utilised. 2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual. ”

    Source location

    Mark Anthony Fernandez · 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

    Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.

    Verbatim wording from the response

    “The Council can also confirm that the commissioned IMCA service is able to cover medical best interest decisions. adult social care will work with them to ensure that where they feel interested persons have not been invited to medical best interest decision meetings, they ensure appropriate information is shared with the organisation leading the decision.”

    Source location

    Response from Oldham Council
    Page 1 · response
    Published 26 March 2025

    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

    Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.

    Verbatim wording from the response

    “Risk rating framework to support practitioners to make safe and informed decisions regarding attendance at medical best interest’s meetings led by other organisations to be created and disseminated across ASC.”

    Source location

    Response from Oldham Council - Action Plan
    Page 1 · response
    Published 26 March 2025

    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

    Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.

    Verbatim wording from the response

    “MCA training”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 6 · response
    Published 26 March 2025

    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

    Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.

    Verbatim wording from the response

    “The Trust Level 3 safeguarding adult mandatory training programme has a significant focus on the MCA and its application in practice. Current organisational compliance with Level 3 Safeguarding adult training is at 95%. MCA and Deprivation of Liberty Safeguards (DoLS) training have been better defined to support the application of MCA beyond the requirement for application of a DoLS authorisation to ensure the MCA is more effectively considered for a wider group of patients, including those with learning disabilities. The application of the MCA is essential to the EPO procedures to ensure the least restrictive option of observation and support is provided.”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 6 · response
    Published 26 March 2025

    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

    Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.

    Verbatim wording from the response

    “MCA audits”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 6 · response
    Published 26 March 2025

    Open published response

  10. North Yorkshire and York

    AI-generated summary

    Stephen Frederick DULLING · 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

    Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

    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 make direct nutritional-needs inquiries of the primary carer

    Wider context from the report

    “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. 5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others. ”

    Source location

    Stephen Frederick DULLING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026