Recurring concern

Failure to recognise dying patients and initiate end-of-life care

First to latest report 11 Feb 2016 — 28 Oct 2016

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes delayed or missed recognition that a patient is dying and failure to initiate the end-of-life pathway directly following that recognition.

What is not included
  • Medication, consultation or advance-care-planning failures not caused by recognition of dying
  • General deterioration recognition where dying is not identified
  • Bereavement and post-death processes

Reports and published responses 3 reports

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

  1. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · 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

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life 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

    Delays in recognising dying patients and initiating end-of-life care

    Wider context from the report

    “22nd May 2016 (1) This was the day (nine days after its application) that hospital staff realised that the sling was incorrectly tied, and of the wrong type, and had caused a long deep Grade 2 pressure sore and necrotic ulcerated area where it had been pressing into the back of Mr Lerner’s neck. Every time he was moved and repositioned this wound will have chaffed and given him extra pain. With regard to his medications: these were either given at a level at which he was completely unable to communicate and co-operate and unable to realise that his family were visiting him, or left him in such pain that he was quite unable to manage it, as a result of this, his dementia and confusion worsened. A wound care nurse referral was made on the 22nd May and he was seen on the 23rd May at 2 p.m. It was not possible now to apply any sling and it wasn’t until a few days after that, that any careful thought was given to supporting his arm and shoulder in such a way as to minimise the pain. From the notes, once the sling had been removed Mr Lerner himself appeared brighter and less confused, however this improvement was short lived. He deteriorated but end of life care was not initiated until the 31st May and he died at 0835 hrs on the morning of the 3rd June. In Court the Elderly Care Consultant accepted that there had been delay in recognising Mr Lerner as a dying patient. This case showed evidence of lack of communication, lack of care, lack of continuity of care, too much use of ‘virtual’ clinics and a general “hands off” attitude towards this patient. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · 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

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

    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 and appropriately manage the dying patient

    Wider context from the report

    “(3) From the 12th September 2015 the recording of doctor's visits, of nurses observations and the processes around the recognition of the dying patient were utterly flawed, unprofessional and unacceptable. I do not propose to rehearse all the things that went wrong since I am quite sure that there should now be a full investigation into what happened by the hospital. This is not the first Regulation 2 report that I have had to write recently (in the last few months) following Inquests and concerning the hospital's failure to recognise the dying patient and act appropriately and in accordance with their own and national guidance. This is a matter which exercises everyone these days particularly following the discussion which arose following the Liverpool Care Pathway AND IT MUST be addressed by this hospital Trust. This abject failure did not, the Jury accepted from the evidence, affect the care that Mrs. Street was given following her fall and head injury. The lack of recognition and the lack of procedures did not affect her and therefore did not either cause or more than minimally contribute to her death, which is why this Regulation 28 Report is so important. These failings did however have a huge impact on her large and loving family who were denied all the support that they should have been given as set out in the End of Life Care Protocols for this Hospital Trust. ”

    Source location

    Christine Valerie STREET · 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

    Hold L8AW nursing study days covering deprivation of liberty, falls prevention, one-to-one care, end-of-life care and documentation.

    Verbatim wording from the response

    “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Establish a ward practice educator role providing neuro-competency and general nursing training.

    Verbatim wording from the response

    “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Marion Rose HOWES · 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

    Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

    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 when a patient is dying

    Wider context from the report

    “(5) There was a failure to recognise the fact that Mrs. Howes was dying. Those looking after her over the last two or three days of her life may have felt under pressure from a demanding family, but families have a right to be demanding as do patients, and doctors and nurses should be able to manage their expectations. The failure to recognise that Mrs. Howes was dying resulted in an undignified and uncomfortable death for her and an enduring and sad memory for her family. ”

    Source location

    Marion Rose HOWES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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