Recurring concern

Failure to reliably record information and advice given to patients

First to latest report 13 Dec 2008 — 2 Apr 2026

Reports that mention this concern: 12
Times this concern has been raised: 12
Stated actions linked to this concern: 16

What this concern includes

Includes failures to record, preserve or accurately represent information, advice or safety-relevant instructions given directly to patients during clinical care, including the anchor's unavailable evidence of information given and failures to document advice allegedly given to a patient.

What is not included

Excludes general clinical or care-record deficiencies where the missing or inaccurate information is not information or advice given directly to a patient.
Excludes failures in the content, appropriateness or accessibility of patient advice where the advice was reliably recorded.
Excludes failures to communicate information to professionals, families or other third parties unless the assertion also concerns recording information or advice given directly to the patient.
Excludes generic documentation, staffing or communication deficiencies that do not specifically concern recording patient-facing information or advice.

Trends

Reports over time

Reports mentioning this concern, 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.

NHS England3

Bolton NHS Foundation Trust1

Carewatch (Mid Bucks)1

Department of Health and Social Care1

Eden Park Surgery1

London Borough of Croydon1

Public Health England1

Recovery Steps Cumbria1

the Shrewsbury and Telford Hospital NHS Trust1

West Midlands Ambulance Service University NHS Foundation Trust1

West Suffolk NHS Foundation Trust1

Wye Valley NHS Trust1

Yorkshire Ambulance Service NHS Trust1

Reports and published responses 12 reports

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

2 Apr2026
Suffolk
Concerns raised1
1. Inadequate recording of important discharge advice
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

West Suffolk NHS Foundation Trust
Stated actions 5
1. West Suffolk NHS Foundation Trust
  Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.
2. West Suffolk NHS Foundation Trust
  Train junior doctors during induction to use standardised discharge-summary #tags.
3. West Suffolk NHS Foundation Trust
  Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.
1. West Suffolk NHS Foundation Trust
  Rectify digital barriers and implement digital enablers for producing discharge letters.
2. West Suffolk NHS Foundation Trust
  Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.
AI-generated summary

David ABBOTT · 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

David ABBOTT underwent surgery at West Suffolk Hospital on 25 October 2023 and was discharged the following day with advice that he interpreted as meaning he should not mobilise. He remained immobile for four days, subsequently developed deep vein thrombosis and pulmonary embolism, and died in cardiac arrest at home on 29 November 2023. Concerns included potentially incorrect discharge advice, inadequate recording of important advice, and ineffective communication between hospital staff, patients and families.

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
Inadequate recording of important discharge advice
Wider context from the report
“West Suffolk Hospital NHS Foundation Trust Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings. At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible. By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs. I am concerned that one or both of the following has occurred: a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error. I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment. ”
Source location
David ABBOTT · 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
Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.

Verbatim wording from the response
“Since 2024, a standardised discharge summary process has been implemented within the Trust. This utilises #tag functionality, allowing clinicians to insert pre-approved, standardised advice directly into discharge documentation.”

Source location
Response from West Suffolk NHS Foundation Trust
Page 1 · response
Published 13 April 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
Train junior doctors during induction to use standardised discharge-summary #tags.

Verbatim wording from the response
“Junior doctors receive training on the use of #tags during their induction, ensuring early awareness and consistent application in clinical practice.”

Source location
Response from West Suffolk NHS Foundation Trust
Page 2 · response
Published 13 April 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
Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.

Verbatim wording from the response
“To address this, consultants have been requested to take ownership of the discharge process and provide check and challenge where appropriate of draft discharge letters.”

Source location
Response from West Suffolk NHS Foundation Trust
Page 3 · response
Published 13 April 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
Rectify digital barriers and implement digital enablers for producing discharge letters.

Verbatim wording from the response
“This incident has reinforced the importance of clear verbal and written communication at discharge. Improving the quality of discharge letters has been a project over the last 18 months led by the Associate Medical Director ████████. This has focused on initially identifying the barriers and the work to address them.”

Source location
Response from West Suffolk NHS Foundation Trust
Page 3 · response
Published 13 April 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
Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.

Verbatim wording from the response
“The digital team have now rectified the digital barriers and have tried to implement the enablers. We have also put in place methods to ensure compliance can be monitored by Clinical Directors and Clinical Leads. It is advised that this data should be discussed at departmental and divisional governance meetings.”

Source location
Response from West Suffolk NHS Foundation Trust
Page 3 · response
Published 13 April 2026
Open published response
16 Mar2026
Cumbria
Concerns raised1
1. Failure to maintain records providing a full and verifiable account of information and assistance provided
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Waythrough Charity (Waythrough
Stated actions 1
1. Waythrough Charity (Waythrough
  Review assessment and documentation practices regularly to support continuous improvement.
Respondent positions 2
1. Waythrough Charity (Waythrough
  Records documented signposting to emergency services, the GP, the CRISIS Team and Samaritans at the initial assessment.
  Disputes the concern
1. Waythrough Charity (Waythrough
  Initial assessment procedures, including risk assessment, recovery planning and follow-up arrangements, were considered robust and appropriate.
  Existing arrangements considered sufficient
AI-generated summary

DARREN ROBERT DICKSON · 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

Darren Robert Dickson was found unresponsive at home after last being seen on 5 February 2025 and died in hospital on 6 February 2025. Toxicology found benzodiazepine and alcohol, and concerns were raised about incomplete records of information and signposting provided by Recovery Steps, and possible confusion or insufficient communication between Recovery Steps and GP services about benzodiazepine use and doses.

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 maintain records providing a full and verifiable account of information and assistance provided
Wider context from the report
“(1) At the appointment on 27 January 2025, Mr Dickson was seen by a Recovery Co-Ordinator in relation to his use of benzodiazepine. It could not be ascertained from the records what information regarding signposting to other services that could have assisted Mr Dickson with treatment, was provided to him. I was concerned that the records did not allow a full and verifiable understanding of the information and assistance provided to Mr Dickson at this appointment. ”
Source location
DARREN ROBERT DICKSON · 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
Review assessment and documentation practices regularly to support continuous improvement.

Verbatim wording from the response
“Waythrough has carefully considered each of the matters of concern set out in your report. We wish to express our sincere condolences to Mr Dickson's family and friends for their loss. The death of any individual known to our services is treated with the utmost seriousness, and we have given detailed consideration to the concerns you have raised.”

Source location
2026-0151 - Response from Recovery Steps
Page 1 · response
Published 18 March 2026
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
Records documented signposting to emergency services, the GP, the CRISIS Team and Samaritans at the initial assessment.

Verbatim wording from the response
“The Coroner's concern is that it could not be ascertained from the records what information regarding signposting to other services was provided to Mr Dickson, and that the records did not allow a full and verifiable understanding of the information and assistance provided at the appointment.”

Source location
2026-0151 - Response from Recovery Steps
Page 3 · response
Published 18 March 2026
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
Initial assessment procedures, including risk assessment, recovery planning and follow-up arrangements, were considered robust and appropriate.

Verbatim wording from the response
“We have reflected carefully on this concern. The records from Mr Dickson’s initial assessment do document specific signposting. In particular, the risk assessment records that Mr Dickson was made aware he could contact emergency services, his GP, the CRISIS Team, and the Samaritans if he required support. An initial Recovery Plan was also completed, setting out Mr Dickson’s personal goals and the next steps in his treatment. A follow-up appointment was arranged and confirmed via text message. Signposting and referral is a core component of RSC’s assessment process under Waythrough’s delivery model.”

Source location
2026-0151 - Response from Recovery Steps
Page 3 · response
Published 18 March 2026
Open published response
9 May2025
South London
Concerns raised1
1. Failure to record the assessment, discussion and advice about the appropriate telecare package
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Croydon
Stated actions 1
1. Croydon
  Record all assessments within the main body of the client record system.
Respondent positions 1
1. Croydon
  Records contained the Careline risk assessment, signed agreement and installation information documenting advice about the service and its cost.
  Disputes the concern
AI-generated summary

Caroline Cleall and Bernard Cleall · 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 and Bernard Cleall, a husband and wife, died together in a house fire at home on 5 January 2022. The report raises concerns that Adult Social Care could not access the earlier assessment and advice about Caroline’s needs and telecare package, limiting proper review of whether an enhanced package with an automatic smoke detector was required.

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 record the assessment, discussion and advice about the appropriate telecare package
Wider context from the report
“(1) The senior manager from LB Croydon Adult Social Care who gave evidence told me that he and his team were unable to access the record of the assessment carried out with Mrs Cleall at Croydon University Hospital for her discharge back to the community. I was told that the record was held by the LIFE team on an NHS system to which LB Croydon Adult Social Care did not have access. (2) The evidence was that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall. (3) It appears that LB Croydon's Adult Services would also not have access to the record and the assessment when reviewing the client’s situation once the package is in place and underway. (4) A review by LB Croydon Adult Social Care was due 4-6 weeks after hospital discharge but it appears that the reviewers had no access to the assessment, advice and response from the client which took place at the hospital. This would mean that the review was missing vital information which might have had a bearing on whether the telecare package should have been revised to include the enhanced service with an automatic smoke detector facility. (5) In summary, I am concerned that the inability of LB Croydon Adult Social Care professionals to access records of an earlier assessment undertaken (and advice given) by their colleagues, together with the NHS LIFE team, deprives LB Croydon Adult Social Care of the ability to review the client’s needs properly (with the necessary information) following discharge into the community. ”
Source location
Caroline Cleall and Bernard Cleall · 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
Record all assessments within the main body of the client record system.

Verbatim wording from the response
“Practice has since changed. Today, all assessments are now completed within the main body our client record system rather than being attached in the “Documents” section, which avoids the sort of confusion that occurred in this instance.”

Source location
Response from London Borough of Croydon
Page 2 · response
Published 20 May 2025
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
Records contained the Careline risk assessment, signed agreement and installation information documenting advice about the service and its cost.

Verbatim wording from the response
“Matter 2: The evidence was that that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall.”

Source location
Response from London Borough of Croydon
Page 2 · response
Published 20 May 2025
Open published response
28 Feb2025
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to record prescribed-drug counselling and safety advice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS England
the Shrewsbury and Telford Hospital NHS Trust
Stated actions 3
1. the Shrewsbury and Telford Hospital NHS Trust
  Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.
2. the Shrewsbury and Telford Hospital NHS Trust
  Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.
3. NHS England
  Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.
AI-generated summary

William Stephen 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

William Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.

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 record prescribed-drug counselling and safety advice
Wider context from the report
“(1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during an admission, no written record is ever made anywhere by anyone including pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the possible side-effects or complications as a result of taking a specific prescribed drug; nor is there any written record on what to look out for and what to do in such circumstances and where they can get assistance. ”
Source location
William Stephen GREEN · 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
Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.

Verbatim wording from the response
“Record of counselling The counselling of a patient in hospital should be undertaken by the medical staff on prescribing the medication, by the nursing staff and pharmacy staff in preparation for discharge. All professions have a role in drug counselling, our pharmacists are the specialists in medication and counselling and have access to additional resources and referral services. Pharmacy led counselling/documentation:”

Source location
Response from Shrewsbury and Telford NHS Trust
Page 1 · response
Published 4 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
Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.

Verbatim wording from the response
“Informed consent/counselling when prescribing a new medication: Treating clinicians have a duty and responsibility to ensure patients are aware of any material risk associated with planned treatment, this includes significant side effects of medication.”

Source location
Response from Shrewsbury and Telford NHS Trust
Page 2 · response
Published 4 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
Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.

Verbatim wording from the response
“However, NHS England will take your concern about counselling, and keeping a written record of such counselling, to an appropriate forum for further discussion and consideration of any actions we need to take.”

Source location
Response from NHSE
Page 2 · response
Published 4 March 2025
Open published response
3 Aug2022
Herefordshire
Concerns raised1
1. Failure to record information given to patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alison June Dallow · 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

Alison June Dallow died from a pulmonary thromboembolism due to deep vein thrombosis after a fractured left tibial plateau and reduced mobility associated with the fracture and a knee brace. The concerns included unclear advice about weight-bearing, unclear hospital policy on reducing venous thromboembolism risk for outpatients, and unavailable evidence of information given to the 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 record information given to patients
Wider context from the report
“(3) Evidence of any information given to the patient was unavailable at the Inquest. ”
Source location
Alison June Dallow · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Dec2020
Black Country
Concerns raised1
1. Failure to record hospital advice and the person's understanding of that advice
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

West Midlands Ambulance Service University NHS Foundation Trust
Stated actions 1
1. West Midlands Ambulance Service University NHS Foundation Trust
  Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
AI-generated summary

Elsie Yvonne Taylor · 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

Elsie Yvonne Taylor, aged 68, fell at home on 15 September 2020, sustained rib fractures and a pneumothorax, and died later the same day after deteriorating in hospital. Concerns included incomplete recording of her reported decision to decline hospital admission and the advice given, lack of information about the consultation and deterioration symptoms, and no attempt to contact her GP or family despite her living alone.

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 record hospital advice and the person's understanding of that advice
Wider context from the report
“(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer; ”
Source location
Elsie Yvonne Taylor · 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
Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.

Verbatim wording from the response
“Response During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts’ expected standard of completing and checking documentation.”

Source location
2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
Page 1 · response
Published 6 January 2021
Open published response
9 Dec2020
South Yorkshire (Western)
Concerns raised1
1. Failure of EPR records to accurately reflect information given to patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Yorkshire Ambulance Service NHS Trust
Stated actions 4
1. Yorkshire Ambulance Service NHS Trust
  Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.
2. Yorkshire Ambulance Service NHS Trust
  Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.
3. Yorkshire Ambulance Service NHS Trust
  Re-audit care-plan documentation after the intervention.
1. Yorkshire Ambulance Service NHS Trust
  Develop EPR tick-box indicators to record information left with patients.
AI-generated summary

Thomas Rawnsley · 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 Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.

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 EPR records to accurately reflect information given to patients
Wider context from the report
“(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient. ”
Source location
Thomas Rawnsley · 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
Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.

Verbatim wording from the response
“The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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
Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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
Re-audit care-plan documentation after the intervention.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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
Develop EPR tick-box indicators to record information left with patients.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
Open published response
21 Aug2018
Manchester West
Concerns raised1
1. Failure to document advice given to patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Bolton NHS Foundation Trust
Stated actions 1
1. Bolton NHS Foundation Trust
  Put relevant safe-sleeping documentation in place.
AI-generated summary

Louie Francis Bradley · 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

Louie Francis Bradley died following breastfeeding in bed with his mother, who fell asleep. Concerns included advice to breastfeed in bed while side-by-side with the baby when the mother was fatigued, and incomplete documentation of key information and advice given to the 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 document advice given to patients
Wider context from the report
“2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented. ”
Source location
Louie Francis Bradley · Prevention of Future Deaths report
Page 1 · 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
Put relevant safe-sleeping documentation in place.

Verbatim wording from the response
“I have attached an Action Plan which details a number of improvements together with the relevant documentation which is now in place for your reference. I hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation.”

Source location
2018-0261-Response-by-Bolton-NHS-Trust
Page 1 · response
Published 25 September 2018
Open published response
1 Aug2018
Inner South London
Concerns raised1
1. Failure to record changes to medication-taking instructions
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Nigel Handscomb · 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

Nigel Handscomb was admitted to University Hospital Lewisham after being diagnosed with pneumonia and possibly having suffered a stroke. He was not reviewed by a doctor for 48 hours, opportunities to escalate his care were missed, and he later suffered a cardiac arrest; the inquest concluded that natural causes, including aspiration pneumonia, bronchopneumonia and severe ketoacidosis, involved neglect. Concerns included incomplete and inaccurate GP records, delayed recording, and missing information about examinations, medication and swallowing difficulties.

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 record changes to medication-taking instructions
Wider context from the report
“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”
Source location
Nigel Handscomb · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Apr2017
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to record advice about inoculation and life-long antibiotic prophylaxis
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Theresa Mary Thompson · 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

Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.

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 record advice about inoculation and life-long antibiotic prophylaxis
Wider context from the report
“At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)). The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital. The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all). ”
Source location
Theresa Mary Thompson · 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.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Inadequate recording of important discharge advice

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to maintain records providing a full and verifiable account of information and assistance provided

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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 record the assessment, discussion and advice about the appropriate telecare package

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to record prescribed-drug counselling and safety advice

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to record information given to patients

Concerns raised1

Failure to record hospital advice and the person's understanding of that advice

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure of EPR records to accurately reflect information given to patients

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Stated actions 5

Stated actions 1

Respondent positions 2

Stated actions 1

Respondent positions 1

Stated actions 3

Stated actions 1

Stated actions 4