Recurring concern

Inadequate safety-netting advice for patients and carers

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First reported 6 May 2016•Latest report 10 Nov 2025

Definition

What this concern includes

Includes failures of safety-netting advice provided to patients, parents, carers or receiving care providers after assessment, treatment, discharge or reported deterioration, including advice that is absent, delayed, undocumented, unclear or not tailored to a material suspected condition.

Not included

Excludes failures of clinical assessment, monitoring, diagnosis or treatment where no safety-netting advice deficiency is identified.
Excludes generic communication or documentation failures that are not specifically part of safety-netting.
Excludes staffing, workload or workforce wellbeing concerns unless the report directly identifies their effect on safety-netting provision.
Excludes emergency call-system or escalation-process deficiencies that do not concern advice given to patients, carers or receiving care providers.

Reports: 29
Individual concerns: 30
Date range: 2016–2025
Stated actions: 24

Reports 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 England6

Department of Health and Social Care5

Barts Health NHS Trust2

East London NHS Foundation Trust2

Barking, Havering and Redbridge University Hospitals NHS Trust1

Barnsley Hospital NHS Foundation Trust1

Betsi Cadwaladr University LHB1

Bristol NHS Foundation Trust1

Chelsea and Westminster Hospital1

Denton Medical Practice1

East Riding of Yorkshire Council1

Essex Partnership University NHS Foundation Trust1

Gateshead Health NHS Foundation Trust1

Greater Manchester Mental Health NHS Foundation Trust1

Hull University Teaching Hospitals NHS Trust1

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.

10 Nov2025
North London
Concerns raised1
1. Failure to provide written instructions including safety netting advice after consultation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jacqueline Aarons · 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

Jacqueline Aarons died at her care home on 19 November 2024 from the consequences of a strangulated umbilical hernia, following vomiting and deterioration over approximately two days. The substantive concerns were the need for a lower threshold for hospital admission for patients with learning disability, face-to-face medical consultation, and clear written safety-netting instructions for care-home staff.

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 written instructions including safety netting advice after consultation
Wider context from the report
“Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability There should be a fact to face consultation by a doctor. Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained. ”
Source location
Jacqueline Aarons · Prevention of Future Deaths report
Page 2 · 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
NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.

Verbatim wording from the response
“In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.”

Source location
Response from Department for Health and Social Care
Page 1 · response
Published 14 November 2025
Open published response
13 Mar2025
Inner North London
Concerns raised1
1. Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.
  Stated by Royal Free London NHS Foundation TrustStated completed
2. Action
  Update existing patient-information guidance to specifically address safety-netting documentation and advice.
  Stated by Royal College of Emergency MedicineStated planned
AI-generated summary

Billie Diane WICKS · 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

Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital 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
Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern
Wider context from the report
“4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. ”
Source location
Billie Diane WICKS · 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
Provide mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.

Verbatim wording from the response
“• All new doctors starting in the Emergency Department, now receive a mandatory teaching session at induction focusing on paediatrics and paediatric deterioration and escalation with regular sessions timetabled ongoing to maintain this education.”

Source location
Response from Royal Free Hospitals
Page 2 · response
Published 17 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
Update existing patient-information guidance to specifically address safety-netting documentation and advice.

Verbatim wording from the response
“RCEM shares your concerns regarding the use of the term ‘safety netting’ in medical notes. This term is only of value if the components of the ‘safety net’ have been documented. RCEM considers the components which relate to safety netting (as opposed to other information which might be provided to the patient) to include: [18]”

Source location
Response from Royal College of Emergency Medicine
Page 2 · response
Published 17 March 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progress
2. Action
  Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.
  Stated by the Shrewsbury and Telford Hospital NHS TrustStated planned
3. Action
  Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.
  Stated by NHS EnglandStated planned
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
24 Jan2025
Inner South London
Concerns raised1
1. Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Charlie Marriage · 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

Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.

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
Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis
Wider context from the report
“(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”. (2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths: (a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply); (b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice); (c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and (d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated. ”
Source location
Charlie Marriage · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Dec2024
Essex
Concerns raised1
1. Failure to provide safety-netting advice to care homes
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

MARY MARGARET WHITLOCK · 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

Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.

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 safety-netting advice to care homes
Wider context from the report
“(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury ”
Source location
MARY MARGARET WHITLOCK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Nov2024
East Riding and Hull
Concerns raised1
1. Unclear advice to callers about calling emergency services back when concerns continue
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 4
1. Position
  Local and system concerns fall outside NHS England’s national policy and programme remit.
  Stated by NHS EnglandOutside remit
1. Position
  Local organisations should address the local and system concerns raised in the report.
  Stated by NHS EnglandRedirects responsibility
2. Position
  Worsening-condition and 999 callback instructions are standard components of the case exit script.
  Stated by NHS EnglandExisting arrangements considered sufficient
3. Position
  The relevant ambulance service must resolve unclear callback instructions locally as a call-handler training issue.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Colin Wiles · 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

Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

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
Unclear advice to callers about calling emergency services back when concerns continue
Wider context from the report
“(2) It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns. ”
Source location
Colin Wiles · Prevention of Future Deaths report
Page 3 · 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
Local and system concerns fall outside NHS England’s national policy and programme remit.

Verbatim wording from the response
“My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
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
Local organisations should address the local and system concerns raised in the report.

Verbatim wording from the response
“My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
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
Worsening-condition and 999 callback instructions are standard components of the case exit script.

Verbatim wording from the response
“You raised the concern that it does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
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
The relevant ambulance service must resolve unclear callback instructions locally as a call-handler training issue.

Verbatim wording from the response
“Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If the call is made via a second party, ambulance services should ensure there is a process in place to be assured the caller is able to monitor the condition of the patient, and that they can be called back when the patient is not able to call back or answer a call themselves. If this was not provided in a clear and easy to interpret manner, this is a matter for the relevant ambulance service to resolve locally as a training issue for their call handlers.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
Open published response
14 Oct2024
North Yorkshire and York
Concerns raised1
1. Failure to provide practical emergency-care advice to carers
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen Frederick DULLING · 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

Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident 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 provide practical emergency-care advice to carers
Wider context from the report
“1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance. 2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police. 3. My concern is that a repetition of such a limited response could present a risk of future deaths to others. ”
Source location
Stephen Frederick DULLING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Sep2024
Inner West London
Concerns raised1
1. Inadequate safety-netting for apparently benign abdominal conditions
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Samuel Finlay Parkin · 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

Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.

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 safety-netting for apparently benign abdominal conditions
Wider context from the report
“4. St George’s has implemented a change in ‘safety netting’ advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is given inviting that “benign abdominal diagnosis“ does not exclude conditions requiring urgent surgical/medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point. ”
Source location
Samuel Finlay Parkin · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Oct2023
East London
Concerns raised1
1. Failure to record clear safety-netting advice to carers
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Claire Twinn · 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

Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.

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 clear safety-netting advice to carers
Wider context from the report
“2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record. ”
Source location
Claire Twinn · Prevention of Future Deaths report
Page 3 · concerns
Open source report
18 Aug2023
Gateshead and South Tyneside
Concerns raised1
1. Absence of documented discharge advice on points of access for concerns or complications
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated in progress
2. Action
  Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated planned
AI-generated summary

William Nichols · 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 Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team record keeping.

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
Absence of documented discharge advice on points of access for concerns or complications
Wider context from the report
“(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding). ”
Source location
William Nichols · 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
Provide patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.

Verbatim wording from the response
“Patients in advance of admission to hospital for their surgery are to be provided with a Femoral Endarterectomy Patient Information Leaflet providing full explanation of their pathology along with the proposed surgery, post operative course and potential complications. The course of action to be taken by patient, community nursing team or GP being provided with the relevant contact points along with phone number to call (see Appendix 1). This is in addition to providing the same information to the patient on discharge in a leaflet Wound care following arterial surgery (see Appendix 2) and in written communication in the discharge summary headed as “Information to Patient” (see Appendix 3).”

Source location
Response from Newcastle Upon Tyne Hospitals NHS Foundation
Page 1 · response
Published 7 September 2023
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
Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.

Verbatim wording from the response
“• Calls from patients about their wounds and the advice given to them should be documented as an entry on e-Records by either the specialist nursing team, or the on-call vascular registrar (or both if they are both involved in the advice), and this entry should be made as close to the time of the call as possible.”

Source location
Response from Newcastle Upon Tyne Hospitals NHS Foundation
Page 2 · response
Published 7 September 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide written instructions including safety netting advice after consultation

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

Concerns raised1

Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to record prescribed-drug counselling and safety advice

Actions described in response 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

Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis

Concerns raised1

Failure to provide safety-netting advice to care homes

Concerns raised1

Unclear advice to callers about calling emergency services back when concerns continue

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to provide practical emergency-care advice to carers

Concerns raised1

Inadequate safety-netting for apparently benign abdominal conditions

Concerns raised1

Failure to record clear safety-netting advice to carers

Concerns raised1

Absence of documented discharge advice on points of access for concerns or complications

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions 1

Actions described in response 2

Actions described in response 3

Respondent positions 4

Actions described in response 2