Recurring concern

Failure to review relevant care documentation before providing care

Pin Get email alerts Request correction

First reported 13 Mar 2017•Latest report 6 Jun 2024

Definition

What this concern includes

Includes failures of care workers or other staff providing direct care to read, review or use available care notes, care plans and related service-user documentation when that information is needed to deliver safe care, including the anchor's failure to read care notes containing wrist-alarm information and failures to review relevant care documentation before care.

Not included

  • Excludes failures caused by records being absent, incomplete, inaccurate or inaccessible when staff review of available documentation is not itself deficient.
  • Excludes failures to read policies, procedures, clinical guidance or custody logs unless the assertion specifically concerns care documentation used to provide care.
  • Excludes failures by clinicians to review medical records or clinical entries where the concern is a distinct clinical-record review process rather than direct review of care documentation by care staff.
  • Excludes generic communication, training, staffing or documentation deficiencies that do not directly involve failure to review relevant care documentation before providing care.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2017–2024

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Ashley Gardens Care Centre1
Care Quality Commission1
Cygnet Behavioural Health Limited1
East London NHS Foundation Trust1
Elm Tree Court Care Home1
HICA Group1
London Borough of Hackney1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1
Supreme Care Services Limited1

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.

  1. Inner North London

    AI-generated summary

    Anoush Summers · 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

    Anoush Summers, a frail woman living alone, fell at home after her wrist alarm had been reported as broken and was found the following day. She was taken to hospital and died of hypothermia on 14 January 2024. Concerns included the failure to repair or replace the alarm, unclear reporting responsibilities, and inadequate instructions or training for carers regarding alarm faults and care notes.

    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 care workers to read care notes containing wrist-alarm information

    Wider context from the report

    “4. The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users. ”

    Source location

    Anoush Summers · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  2. East Riding and Hull

    AI-generated summary

    Robert Norman Howell · 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

    Robert Norman Howell, who was susceptible to falls, fell backwards in his room at Elm Tree Court care home on 12 April 2022 and struck his head. He sustained a subdural haematoma and died in hospital on 20 April 2022. Concerns included failures to share vital information about residents’ falls risks and care needs, inadequate access to care plans, and a lack of understanding of falls policies.

    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 care staff read and familiarise themselves with care plans and residents’ needs and risks

    Wider context from the report

    “(2) Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care. ”

    Source location

    Robert Norman Howell · 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

    Introduce electronic care planning with current care plans, records and risk assessments available to staff at the point of care.

    Verbatim wording from the response

    “HICA Response. HICA has always had a process in place that formal handovers occur between shifts for staff. Staff should attend the handover meeting, but we did not have a system in place to record attendance at handovers. We have now introduced a standard handover template and attendance sheet into all services. In addition to this, we have introduced electronic care planning, whereby staff have access to up to date care plans, records, and risk assessments for each resident, at the point of care delivery.”

    Source location

    Response from HICA Group
    Page 1 · response
    Published 6 October 2022

    Open published response
  3. Bedfordshire and Luton

    AI-generated summary

    Mr Thomas Antony 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

    Mr Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.

    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 escorting staff receive and review patient-specific risk information before s.17 leave

    Wider context from the report

    “2) The system for assessing risks associated with s.17 leave I was told that, when a staff member is escorting a service user out of the ward, there is an expectation for that staff member to be aware of the location, general mental state and wellbeing of the service user; and that a ‘mental state assessment’ should be carried out on the ward prior to leave taking place, as a further safeguard once s.17 leave had been granted. However, the evidence of the healthcare assistant who took Mr Smith out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the ████████ the misuse of which caused his death, was that: (i) He would not necessarily read a patient’s RiO (electronic continuous) notes before taking a patient out on leave; (ii) He had not read Mr Smith’s care plan before taking him on leave; (iii) There had been no handover from other staff to him of Mr Smith’s presentation on 28 December 2020 presentation (when he was suspected of being ‘under the influence’ of a substance); and (iv) Although he had read the form authorising Mr Smith’s leave (i.e. the s.17 form), that form – a statutory document – does not contain information about particular risks posed to a patient by or when out on s.17 leave. As a result of the above, this particular healthcare assistant was unaware that: (i) On 28 December 2020 Mr Smith had been suspected of being under the influence of drugs; (ii) Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact that “Thomas has a history of using illicit substances”; and (iii) The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do random urine drug screening and breathalysing upon return to the ward.” The healthcare assistant therefore appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan. There was, however, no suggestion in the evidence of any witness during Mr Smith’s inquest that the situation in which the escorting healthcare assistant found himself represented a failure to follow policy or expected procedure. In the event that this is correct there appears to be a wider issue – and this Report is therefore directed to NHS England and NHS Improvement. ”

    Source location

    Mr Thomas Antony Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  4. Mid Kent and Medway

    AI-generated summary

    Norman Barnes · 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

    Norman Barnes died after choking on food while eating lunch at Ashley Gardens Care Centre. His meal was not prepared as minced or moist, contrary to the recommendation in his SALT assessment and care plan. Staff were aware of his Parkinson’s disease but were not aware of, or did not refer to, key information in his care plan and risk assessments.

    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 care home staff to refer to care plans and risk assessments when delivering patients’ daily needs

    Wider context from the report

    “Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that: (1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident. (2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents. ”

    Source location

    Norman Barnes · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. Norfolk

    AI-generated summary

    Nyall Cye BROWN · 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

    Nyall Cye Brown was found hanging in woodland on 17 May 2018 and died in hospital on 22 May 2018. Concerns included that his care records were not reviewed before he was assessed, meaning his full history and risks could not be taken into account, and that this issue had been raised previously but was not always addressed. The issue was also not considered in the Trust’s 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

    Failure to review previous care records before assessing a service user

    Wider context from the report

    “1. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him. 2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening. 3. This matter was not considered in the otherwise thorough investigation conducted by the Trust. ”

    Source location

    Nyall Cye BROWN · 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

    Deliver a learning session on record keeping, communication and preparation before appointments.

    Verbatim wording from the response

    “The Trust has commissioned a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager commencing in June 2019. Alongside a focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication, the session will include content related to the importance of preparation ahead of appointments.”

    Source location

    2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 14 June 2019

    Open published response
  6. Inner South London

    AI-generated summary

    James O’Brien · 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

    James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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 agency nurses read patients' care plans before starting duties

    Wider context from the report

    “(9) The agency nurse in charge of the ward was called shortly before the shift started, was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties. ”

    Source location

    James O’Brien · Prevention of Future Deaths report
    Page 1 · 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

    The former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 2017

    Open published response
Back to top

Data last updated 7 September 2026