Recurring concern

Failure to reliably implement multidisciplinary team recommendations

First to latest report 30 Dec 2015 — 10 Feb 2023

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures within the dedicated multidisciplinary team recommendation process, including recording agreed actions, communicating outcomes to responsible clinicians, assigning responsibility, tracking follow-up and completing recommendations, including the anchor's uncompleted colorectal follow-up.

What is not included
  • Excludes generic care-plan, communication, documentation or follow-up deficiencies unless they specifically concern recommendations or actions arising from a multidisciplinary team.
  • Excludes failures to convene or staff multidisciplinary meetings where no resulting recommendation or action implementation failure is identified.
  • Excludes clinical disagreements or decisions to depart from a recommendation where the departure is formally considered, documented and safely managed.
  • Excludes recommendations from individual clinicians or services unless they are explicitly part of a multidisciplinary team decision or recommendation.

Reports and published responses 4 reports

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

  1. Manchester South

    AI-generated summary

    Sandra Adina Lomax · 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

    Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

    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 MDT to effectively communicate agreed actions and recommendations for individual patients

    Wider context from the report

    “4. This was compounded by the fact that the inquest heard evidence that the MDT did not have a system of effective communication of agreed actions and recommendations for individual patients discussed at the MDT. As a consequence local clinicians were unsighted as to the recommended way forward. The inquest was told that an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes. ”

    Source location

    Sandra Adina Lomax · 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

    Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.

    Verbatim wording from the response

    “Recognising the challenges in relation to MDT working, the Greater Manchester Cancer Alliance have an improvement programme in place in relation to MDT reform:”

    Source location

    Response from Greater Manchester Integrated Care
    Page 3 · response
    Published 24 February 2023

    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

    Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.

    Verbatim wording from the response

    “GM are the appropriate organisation to respond to your concerns around GM staffing issues and ineffective communication between the MDT. I have been sighted on their response and welcome the Greater Manchester Cancer Alliance improvement programme for MDT reform. I also note that they will be sharing learning from Sandra’s death across the Greater Manchester System.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 February 2023

    Open published response

  2. Manchester City

    AI-generated summary

    Name not published · 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

    The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.

    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 hold necessary MDT meetings and complete resulting actions

    Wider context from the report

    “1. There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Linda Doherty · 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

    Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on 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

    Failure to action recommendations stemming from multidisciplinary team meetings

    Wider context from the report

    “1. There was no colorectal follow up in relation to the findings of the CT scan carried out on 2 December 2016 despite it being recommended by the Upper Gastro-Intestinal Multi-Disciplinary Team meeting at East Surrey Hospital on 20 December 2016. Consideration should be given as to whether the appropriate procedures are in place to ensure that recommendations stemming from MDT meetings are actioned appropriately. ”

    Source location

    Linda Doherty · Prevention of Future Deaths report
    Page 4 · 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

    Existing databases, tracking, cancer nurse specialist monitoring and escalation arrangements support appropriate follow-up of MDT recommendations.

    Verbatim wording from the response

    “The current arrangements for the follow up of the recommendations made at the Upper GI MDT meeting were reviewed. The outcome for all patients discussed at the MDT meeting, whether cancer patients or not, are recorded on the Somerset database (a digital platform designed for healthcare professionals to manage cancer patient care). This is monitored by cancer services trackers who are then able to escalate to the most appropriate person any concerns i.e. tests not being requested and will chase dates as needed.”

    Source location

    2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
    Page 8 · response
    Published 21 December 2020

    Open published response

  4. Manchester West

    AI-generated summary

    Mollie Bentham · 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

    Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

    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 document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes

    Wider context from the report

    “1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”

    Source location

    Mollie Bentham · 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

    Review multidisciplinary team meetings and paperwork, and address poor documentation and failures to follow up meeting actions through a task-and-finish group.

    Verbatim wording from the response

    “A review of the conduct of MDT meetings including evaluation of the paperwork used at the meetings has been lead by Ann Lloyd, Consultant Nurse for Older People. ████████ has set up a task and finish group and taken steps to address the issues of poor documentation and failure to follow up actions identified at MDT meetings. I am advised this work is still ongoing however its purpose will be to ensure there is improved clinical decision making from all disciplines attending the MDT with appropriate timescales set for actions to be taken and completed, ultimately this will facilitate the safe discharge of our patients. It is expected that this work will be complete by 31 March 2016.”

    Source location

    Mollie-Bentham-Response
    Page 2 · response
    Published 30 December 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