Recurring concern

Inadequate support for vulnerable patients during healthcare assessment and decisions

First to latest report 14 Nov 2017 — 23 Aug 2021

Reports that mention this concern: 5
Times this concern has been raised: 5
Stated actions linked to this concern: 2

What this concern includes

Includes failures to provide or arrange appropriate support for vulnerable patients during healthcare assessments, consultations or related care decisions when the support is needed to obtain an accurate clinical picture or enable meaningful decision-making.

What is not included

Excludes generic communication, family-contact or social-support failures where support during a healthcare assessment or care decision is not the unsafe condition.
Excludes failures limited to clinical assessment quality, history-taking or decision-making where the patient had appropriate support available.
Excludes reasonable-adjustment, interpreter, advocacy or consent-process concerns when those separately named systems provide the more specific supported boundary.
Excludes general resource shortages or lack of support outside a healthcare assessment, consultation or related care decision.

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.

Department of Health and Social Care2

NHS England2

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Beech Cliffe Grange1

Beech Cliffe Limited1

Care Quality Commission1

Greater Manchester Health and Social Care Partnership1

Reports and published responses 5 reports

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

23 Aug2021
Manchester South
Concerns raised1
1. Lack of support for vulnerable patients during hospital assessment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 1
1. Department of Health and Social Care
  Local NHS Trusts are responsible for determining hospital visiting arrangements within national principles and their own safety assessments.
  Redirects responsibility
AI-generated summary

Maurice Leech · 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

Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of support for vulnerable patients during hospital assessment
Wider context from the report
“2. Mr Leech was very vulnerable and a poor historian. Due to Covid he was sent alone to hospital and seen alone there. The evidence before the inquest was that if support had been available a more accurate picture of his baseline and needs would have assisted staff in treating him and potentially identifying that he should not be discharged back to the care home and that a fracture would not have been missed. ”
Source location
Maurice Leech · 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
Local NHS Trusts are responsible for determining hospital visiting arrangements within national principles and their own safety assessments.

Verbatim wording from the response
“Since the end of the national lockdown in England, visiting in hospitals is now subject to the discretion of local NHS Trusts, based on the national principles, which will make their own assessment as to the visiting arrangements that can safely be put in place. Careful hospital visiting policies remain appropriate while COVID-19 continues to be in general circulation and organisations can exercise discretion where COVID-19 rates are higher. The health, safety and wellbeing of patients, communities and staff remains the priority.”

Source location
2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 3 · response
Published 26 August 2021
Open published response
23 Aug2021
Manchester South
Concerns raised1
1. Lack of support for vulnerable patients and their decision making at outpatient appointments
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

Norma Rushworth · 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

Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication 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
Lack of support for vulnerable patients and their decision making at outpatient appointments
Wider context from the report
“1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making. ”
Source location
Norma Rushworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Feb2021
Manchester South
Concerns raised1
1. Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Care Quality Commission
Department of Health and Social Care
Stated actions 1
1. Department of Health and Social Care
  Highlight links to RESTORE2 and British Geriatrics Society guidance more explicitly in care-home admissions guidance.
Respondent positions 1
1. Care Quality Commission
  The existing red bag scheme and hospital passport were considered sufficient to address risks during Mrs Jones’s transfer to hospital.
  Existing arrangements considered sufficient
AI-generated summary

Ruth Jones · 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

Ruth Jones, a resident of The Beeches Care Home who was at risk of falls, fell while unobserved after being isolated because Covid-19 was suspected. She was admitted to hospital with a fractured neck of femur and bronchopneumonia and later died there. Concerns included the lack of guidance and staffing arrangements for safely observing residents at risk of falls during required isolation, and the difficulties caused when frail patients attended hospital without family support.

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 support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment
Wider context from the report
“2. When Mrs Jones had to go to hospital she was sent alone and her family could not go with her due to Covid 19 restrictions. The inquest heard that Mrs Jones was frail and vulnerable. The inquest was told that the unsupported presentation/assessment of vulnerable, frail and elderly patients such as Mrs Jones presented significant problems to clinicians in terms of effective communication and understanding their health baseline to support appropriate and timely clinical decision making. ”
Source location
Ruth Jones · 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
Highlight links to RESTORE2 and British Geriatrics Society guidance more explicitly in care-home admissions guidance.

Verbatim wording from the response
“You may also wish to note that guidance in April 2020, Coronavirus (COVID-19): admissions and care of people in care homes², contained a link to RESTORE2³, a physical deterioration and escalation tool for care and nursing homes, as well as guidance on managing COVID-19 and care homes, published by the British Geriatrics Society⁴. These sources provide clear guidance on the importance of providing a concise escalation history to health professionals to support their professional decision making, and advance care planning. Reference is also made in the guidance to Enhanced Health in Care Homes⁵, a new, proactive model of care, centred on the needs of the individual.”

Source location
2021-0038-Response-from-Dept.-of-Health-Social-Care-Redacted
Page 2 · response
Published 15 February 2021
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 existing red bag scheme and hospital passport were considered sufficient to address risks during Mrs Jones’s transfer to hospital.

Verbatim wording from the response
“The Beeches participated in the red bag scheme. This is a national scheme that assists care home residents admitted to hospital to be discharged quicker. The bags contain key paperwork (hospital passport), medication and personal items like glasses, slippers and dentures. The hospital passport contained relevant information about the individual’s current needs, a brief medical history, as well as important contact details and other relevant information about a person’s preferences. These are handed to ambulance”

Source location
2021-0038-Response-from-CQC-Redacted
Page 5 · response
Published 15 February 2021
Open published response
5 Apr2019
Surrey
Concerns raised1
1. Failure to provide assistance when obtaining consent from vulnerable patients
This report raised 10 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

Mrs Alice Doris Dixon · 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

Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

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 assistance when obtaining consent from vulnerable patients
Wider context from the report
“3. The consent form was filled in by the radiographer on asking questions of Mrs Dixon alone who was vulnerable, unwell, confused and hard of hearing in an unfamiliar environment without assistance. ”
Source location
Mrs Alice Doris Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Nov2017
South Yorkshire (Eastern)
Concerns raised1
1. Failure to ensure the resident and one-to-one carer attend general-practitioner consultations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Beech Cliffe Limited
Stated actions 1
1. Beech Cliffe Limited
  Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.
Respondent positions 1
1. Beech Cliffe Limited
  The resident’s absence from the GP consultation was treated as a justified one-off decision based on infection and behavioural concerns.
  Disputes the concern
AI-generated summary

Steven Jones · 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

Steven Jones, aged 27, was a non-verbal resident of a care home who became ill with sickness, diarrhoea, loss of appetite and sleep disturbance before dying on 10 December 2013. He was diagnosed with a perforated colon, leading to multi-organ failure and hypoxic brain injury. Concerns included failures to escalate carers’ concerns, insufficient incident reporting, delayed medical referral, and delays in calling emergency services and transferring him to hospital.

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 the resident and one-to-one carer attend general-practitioner consultations
Wider context from the report
“(5) In the case of a non-verbal resident with serious problems very early referral to a general practitioner was not made and when made the resident was not present at the consultation nor was his one to one carer in attendance. ”
Source location
Steven Jones · 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
Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.

Verbatim wording from the response
“In June 2014 the Anticipatory HealthCare Calendar (AHCC) was introduced. ████████ raised the introduction of this system in her evidence to the Inquest on 9 November 2017. This is a NHS proforma that acts as a criteria-referenced monitoring system for health-related issues in those with learning disabilities. Specific symptoms are listed and given a risk level of Green, Amber or Red; amber and red directly link to required specific staff actions and responses, which are described within the tool and recorded on a Significant Communication Sheet, part of the tool. These range from continued monitoring, through administering pain relief or attending a GP surgery when possible, to contacting emergency services immediately. AHCC is a career-level tool that is directive in terms of response to specific symptoms.”

Source location
2017-0357-Response-by-Beech-Cliffe-Limited
Page 3 · response
Published 11 February 2018
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 resident’s absence from the GP consultation was treated as a justified one-off decision based on infection and behavioural concerns.

Verbatim wording from the response
“As set out at paragraph 17 of her witness statement dated 4 October 2017, paragraph 20 of her witness statement dated 4 April 2016 and in evidence to the Inquest on 9 November 2017 Sarah did not take Steven to the appointment on 28 November 2013 because she was concerned that due to his diarrhoea and the unknown result of the stool sample he could be infectious. Also Steven had previously exhibited anxious and challenging behaviour at appointments. She explained her reasoning to the GP, ███████ who was happy to proceed with the appointment. When asked by the Coroner on 8 November 2016 ███████ confirmed that he could have insisted on seeing Steven either at the GP surgery or at the Home.”

Source location
2017-0357-Response-by-Beech-Cliffe-Limited
Page 6 · response
Published 11 February 2018
Open published response

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

Lack of support for vulnerable patients during hospital assessment

Linked response

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

Concerns raised1

Lack of support for vulnerable patients and their decision making at outpatient appointments

Concerns raised1

Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment

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.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 provide assistance when obtaining consent from vulnerable patients

Concerns raised1

Failure to ensure the resident and one-to-one carer attend general-practitioner consultations

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

Respondent positions 1

Stated actions 1

Respondent positions 1

Stated actions 1

Respondent positions 1