Recurring concern

Failure to provide trauma-informed hospital care

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First reported 16 Feb 2017•Latest report 27 May 2026

Definition

What this concern includes

Includes failures in hospital assessment, treatment planning, communication or care delivery where the report explicitly identifies a failure to recognise or respond to trauma or the traumatic impact of hospital treatment.

Not included

Excludes generic failures to individualise care where trauma-related needs are not identified.
Excludes mental-health or psychological treatment failures outside the provision of hospital care unless the assertion directly concerns trauma-informed hospital treatment.
Excludes generic communication, documentation, staffing or training deficiencies that are not specifically tied to recognising or responding to trauma-related needs.
Excludes ordinary discomfort or distress during hospital treatment where no failure to provide trauma-informed care is identified.

Reports: 4
Individual concerns: 4
Date range: 2017–2026
Stated actions: 0

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Churchgate Surgery1

Department of Health and Social Care1

East Suffolk and North Essex NHS Foundation Trust1

Mid and South Essex NHS Foundation Trust1

NHS England1

NHS Greater Manchester Integrated Care Board1

Pennine Care NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

27 May2026
Essex
Concerns raised1
1. Failure to incorporate relevant previous restraint and trauma history into admission care
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Abigail Louise SMITH · 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 Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

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 incorporate relevant previous restraint and trauma history into admission care
Wider context from the report
“2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission. ”
Source location
Abigail Louise SMITH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Jun2024
Essex
Concerns raised1
1. Failure to factor complex trauma and difficulty being in hospital into treatment planning
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
1. Position
  East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Chloe HUNT · 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

Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.

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 factor complex trauma and difficulty being in hospital into treatment planning
Wider context from the report
“a. Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of complex trauma and how difficult she found it to be in hospital. This was not factored into a plan for treatment. ”
Source location
Chloe HUNT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.

Verbatim wording from the response
“Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

Source location
Response from NHS England
Page 1 · response
Published 26 June 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
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.

Verbatim wording from the response
“Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

Source location
Response from NHS England
Page 1 · response
Published 26 June 2024
Open published response
30 Sep2019
Manchester South
Concerns raised1
1. Failure to provide trauma-informed hospital care
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Julie Ann Barrow · 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

Julie Ann Barrow, who had significant learning disabilities, was admitted to hospital on several occasions for perianal pain, rectal bleeding and haemorrhoids. Following treatment for adjustment disorder and significant sedation, she fell at her family home on 1 April 2019, sustained an unsurvivable brain injury and died in hospital the next day. The principal concerns included the absence of a best interests meeting and reasonable adjustment care plan, ineffective communication and understanding of her needs, inadequate support for her parents, and the loss of the learning disability liaison role.

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 provide trauma-informed hospital care
Wider context from the report
“3. Julie Ann Barrow was cared for devotedly in hospital by her parents who are in their 80s. Their evidence to the inquest was that Julie was never effectively communicated with by clinicians treating her and her needs not understood. So far as her needs were concerned she was “invisible” to staff. An approach that recognised just how traumatic a hospital stay and medical treatment was for her would have significantly reduced the trauma that led to her developing adjustment disorder. The consultant psychiatrist who gave evidence to the inquest was very clear that the pain and trauma of the hospital stays had caused the acute adjustment disorder; ”
Source location
Julie Ann Barrow · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Feb2017
Manchester South
Concerns raised1
1. Lack of treatment plans addressing complex PTSD
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Josef 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

Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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
Lack of treatment plans addressing complex PTSD
Wider context from the report
“2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. ”
Source location
Thomas Josef Green · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to incorporate relevant previous restraint and trauma history into admission care

Concerns raised1

Failure to factor complex trauma and difficulty being in hospital into treatment planning

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to provide trauma-informed hospital care

Concerns raised1

Lack of treatment plans addressing complex PTSD

Respondent positions 2