Recurring concern

Failure to reliably notify responsible consultants about admissions and significant clinical changes

First to latest report 13 Dec 2013 — 3 Dec 2024

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
7

What this concern includes

Includes failures to identify, route, communicate, acknowledge or escalate material information about a patient's admission or significant clinical change to the consultant responsible for the patient's care, including pre-admission risk information and significant events requiring consultant review.

What is not included
  • Excludes generic communication or handover failures where notification to a responsible consultant is not the bounded safety control.
  • Excludes failures in consultant review or clinical leadership after the consultant has been reliably notified.
  • Excludes notifications to GPs, families, emergency services or non-consultant clinicians unless the assertion directly concerns the responsible consultant notification process.
  • Excludes routine clinical information that does not materially affect admission awareness, senior review or patient-safety decisions.

Reports and published responses 7 reports

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

  1. Inner North London

    AI-generated summary

    Mnayea ZMF Al Basman · 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

    Mnayea ZMF Al Basman, who had significant co-morbidities, underwent a right hemicolectomy for caecal adenocarcinoma and died in hospital on 25 March 2024 after developing sepsis and peritonitis caused by an anastomotic leak. Concerns included failure to escalate aspects of his deterioration to the consultant surgeon, insufficient professional curiosity, inadequate overnight observation planning, and a lack of detail in some records. The report also noted that the events preceding his death had not been subject to an internal investigation, providing little reassurance that these matters had been addressed.

    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 inform and consult the consultant about the clinical presentation

    Wider context from the report

    “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend: • a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis; • some entries in the clinical notes may have been ‘falsely reassuring’; • the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team; • there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and • there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024. 2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not. 3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail. Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed. ”

    Source location

    Mnayea ZMF Al Basman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Surrey

    AI-generated summary

    Freda Mary Lennox · 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

    Freda Mary Lennox, an 86-year-old woman with significant idiopathic pulmonary fibrosis and other medical comorbidities, was admitted for an elective total hip replacement and died on 4 November 2020 after experiencing a cardio-respiratory arrest at the end of the procedure. Concerns included incomplete pre-operative assessment, a lack of recent orthopaedic and anaesthetic review before admission, and inadequate resources for a dedicated high-risk anaesthetic assessment service.

    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 inform the consultant anaesthetist about patients and their medical co-morbidities before admission

    Wider context from the report

    “3. The consultant anaesthetist was not informed about Mrs Lennox and her medical co-morbidities prior to her admission. Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs Lennox consented for surgery. ”

    Source location

    Freda Mary Lennox · 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

    Create a dedicated electronic referral pathway for high-risk clinics and formalise patient risk assessments visible to relevant pre-operative staff.

    Verbatim wording from the response

    “The Trust introduced an electronic patient record system in 2022, called Surrey Safe Care (SCC). We have created a specific SSC pathway for referral into the high-risk clinic that sits separately to the standard pre-operative assessment referral pathway. This requires a referral by a consultant surgeon. The SCC system also allows for a range of formalised patient risk assessments and recognised scoring systems individualised to the patient as appropriate. These risk assessments are visible to all relevant staff with the aim of adequately informing anaesthetists and others, pre-operatively about their patient’s risk status.”

    Source location

    Response from St Peter's Hospital
    Page 2 · response
    Published 12 May 2022

    Open published response

  3. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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

    Delay in escalating falls to the responsible consultant

    Wider context from the report

    “5. The consultant in charge of Mrs Tuck’s care did not learn of the 15 October fall until 17 October. It seems that the junior doctors on her ward did not bring this to her attention. Mrs Tuck’s nephew, however, was gravely concerned to find his auntie unable to communicate, and brought this to the attention of the consultant. The consultant asked him “What do you want me to do, scan her brain?” and he replied “I think that would be a very good idea”. Hence a CT scan was conducted on the afternoon of 17 October. ”

    Source location

    Margaret Emily TUCK · 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

    Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response

  4. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 timely obstetric consultant supervision after emergency admission

    Wider context from the report

    “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission. Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission. ”

    Source location

    Rhi anne Anoushka Florence BARTON · 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

    Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.

    Verbatim wording from the response

    “We have actioned a change in Consultant working practices to facilitate timely review of patients on Joan Booker Ward. The default planning is that Consultants will review patients under their care every working day; where other commitments or absences preclude this, and at weekends, the labour ward Consultant will review the patients. This pattern of working has been in place since March 2015. I have included as Appendix 1, the details of this working pattern.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 1 · response
    Published 1 June 2016

    Open published response

  5. Black Country

    AI-generated summary

    Kirsty Lisa Pritchard · 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

    Kirsty Lisa Pritchard had complex medical needs and a history of self-harm and suicidal ideation. After being discharged from hospital, she contacted the community team several times reporting thoughts of self-harm and suicide; she was later found deceased at home, hanging with a belt around her neck, and was pronounced deceased at 14:15 on 20 January 2013. The report raised concerns about delayed communication of worsening symptoms and risk to the responsible consultant, and deficiencies in systems for contacting and locating her after an immediate risk was reported.

    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 ensure that the responsible consultant is made aware of worsening symptoms after discharge

    Wider context from the report

    “(2) I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this. ”

    Source location

    Kirsty Lisa Pritchard · 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

    Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.

    Verbatim wording from the response

    “• The communication with consultants to raise any concerns has been reinforced by recirculating the medical escalation flow chart (Appendix 1) to all CHITT and inpatient staff both clinical and non-clinical so that it is clear which individual any concerns about risk should be raised with.”

    Source location

    2014-0565-Response-by-Black-County-NHS-Trust_Redacted
    Page 2 · response
    Published 17 October 2014

    Open published response

  6. Inner South London

    AI-generated summary

    Miss Abiola Dosunmu · 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

    Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.

    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 inform the consultant of the patient and imminent self-discharge before discharge

    Wider context from the report

    “(5) Before discharge neither the patient nor the imminent self discharge were not known to the consultant, who would have wished to be informed and would have sought further investigations and communications. ”

    Source location

    Miss Abiola Dosunmu · 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

    Notify consultants within 12 hours when their patient self-discharges from hospital.

    Verbatim wording from the response

    “The medical records (in particular the clinical noted dated 09.03.12 at 13.25 hours) suggest that the Trust communicated the significance of Abiola’s illness as it was understood at the time and did its best to dissuade her from leaving hospital. The Trust is satisfied that it acted appropriately by warning Abiola and her mother of the serious consequences of self-discharging. Nonetheless, with immediate effect consultants will be notified within 12 hours that their patient has discharged themselves from hospital to minimise the potential risk to the patient or others (see also paragraph 5 below).”

    Source location

    2014-0209-Response-by-Kings-College-Hospital
    Page 1 · response
    Published 5 May 2014

    Open published response

  7. Manchester City

    AI-generated summary

    STEPHANIE DANIELS · 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

    Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal 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

    Lack of a reliable method for notifying the responsible Consultant of patient admission

    Wider context from the report

    “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem. ”

    Source location

    STEPHANIE DANIELS · Prevention of Future Deaths report
    Page 10 · 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 admission-checklist sign-offs to confirm doctor clerking, physical examination, and consultant notification of hospital admissions.

    Verbatim wording from the response

    “The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that they have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in. It also incorporates the action to inform the consultant by email of hospital admissions. This will be monitored through audits.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 13 December 2013

    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

    Audit compliance with admission clerking and consultant-notification requirements.

    Verbatim wording from the response

    “The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that they have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in. It also incorporates the action to inform the consultant by email of hospital admissions. This will be monitored through audits.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 13 December 2013

    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

    Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

    Verbatim wording from the response

    “As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

    Source location

    2013-0353-Response-by-Department-of-Health
    Page 1 · response
    Published 13 December 2013

    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