Recurring concern

Unreliable consent controls for safety-critical information sharing

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First reported 27 Oct 2016•Latest report 31 Jan 2025

Definition

What this concern includes

Includes failures in dedicated processes for seeking, revisiting, recording and applying a person's consent when safety-critical information is to be shared with family, carers, healthcare professionals, emergency services or other directly relevant recipients, including the anchor's missing policy for repeated proactive consent-seeking and failures to ask about consent before sharing suicidal-risk or hospital-attendance information.

Not included

  • Excludes general confidentiality or information-sharing failures where consent for disclosure is not the deficient control.
  • Excludes failures involving informed consent for examination, treatment or procedures, which concern treatment consent rather than consent to share information.
  • Excludes failures to involve families, carers or professionals after consent has been reliably established, unless the consent-control process itself was deficient.
  • Excludes disclosures or non-disclosures that are legally required or permitted independently of the person's consent, where no failure in the applicable consent process is identified.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2016–2025

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.

Arts University Bournemouth1
Department of Health and Social Care1
Devon Partnership NHS Trust1
Dorset Healthcare University NHS Foundation Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
HM Prison and Probation Service1
Ison Harrison Limited1
North Yorkshire Police1
Oxleas NHS Foundation Trust1
Rochester Prison1
Suffolk Safeguarding Partnership1
The Limes Residents Association Limited1
Yorkshire Ambulance Service 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.

  1. Suffolk

    AI-generated summary

    Kim Jeannette ROBINSON · 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

    Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.

    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 require consent and notify current or regular practitioners about online prescriptions

    Wider context from the report

    “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made. The GP stated there was:- a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber. b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted. c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed. d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies. Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim. In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed. 2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017. ”

    Source location

    Kim Jeannette ROBINSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Dorset

    AI-generated summary

    Alexander Channing · 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

    Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and 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

    Absence of a policy encouraging repeated proactive approaches to obtaining patient consent for information sharing

    Wider context from the report

    “iv. There is no policy in place at Devon Partnership NHS Trust which encourages a repeated proactive approach in seeking consent from a patient to share information at relevant times. ”

    Source location

    Alexander Channing · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. Mid Kent and Medway

    AI-generated summary

    John Allen Martin HENDERSON · 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

    John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison 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

    Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers

    Wider context from the report

    “I asked additional questions of witnesses and asked to have sight of policies and procedures in respect of information sharing protocols and procedures in respect of prisoners with chronic conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes. My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front line prison staff may not be made aware of what was causing the issue or how to respond thereto. ”

    Source location

    John Allen Martin HENDERSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.

    Verbatim wording from the response

    “Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.”

    Source location

    Response from Oxleas Forensic and Offender Healthcare Services
    Page 1 · response
    Published 25 January 2023

    Open published response
  4. Suffolk

    AI-generated summary

    May Adalaid Miller · 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

    May Adalaid Miller, aged 95, was attacked by another resident while asleep at Beech House Residential Care Home on 9 February 2020 and died from natural causes precipitated by the assault. The report raised concerns about the lack of safeguarding information sharing between agencies and care facilities, including the absence of a system to share information about the other resident’s risk factors.

    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 obtain consent for disclosure of safeguarding information to other agencies

    Wider context from the report

    “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes. It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible. Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller. ”

    Source location

    May Adalaid Miller · 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

    GP confidentiality means the suitability information received about prospective residents is very limited.

    Verbatim wording from the response

    “Prospective residents are interviewed by the warden and the manager. A letter of suitability is always obtained from the G.P. but they seemed to be bound by confidentiality and the information is received is very limited.”

    Source location

    2020-0201-Response-from-the-Limes-Residence-Association_Redacted.pdf
    Page 1 · response
    Published 1 December 2020

    Open published response
  5. Southampton and New Forest

    AI-generated summary

    Eleanor Valerie Fyfe BRABANT · 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

    On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

    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 implementation of information-sharing arrangements when patients withdraw family consent

    Wider context from the report

    “5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. North Yorkshire (West)

    AI-generated summary

    Samuel Thomas Lindor Carroll · 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 Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.

    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 ambulance services to ask for consent before sharing information about suicidal feelings or hospital attendance

    Wider context from the report

    “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital. 2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital. 3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation. ”

    Source location

    Samuel Thomas Lindor Carroll · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 police officers to ask for consent before sharing information about suicidal feelings or hospital attendance

    Wider context from the report

    “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital. 2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital. 3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation. ”

    Source location

    Samuel Thomas Lindor Carroll · 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

    Add instruction to training on eliciting consent to inform a nominated person about a suicidal individual's location and mental wellbeing concerns.

    Verbatim wording from the response

    “In light of your report, I will make sure that this training includes instruction to staff to make sure that steps are taken to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing. This must be balanced against considerations of whether that nominated person may potentially exacerbate the situation, given that feelings of suicidality often emanate from relationship / familial difficulties.”

    Source location

    2016-0384-Response-by-North-Yorkshire-Police
    Page 2 · response
    Published 27 October 2016

    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 evidential basis for concluding that ambulance clinicians failed to ask about contacting family is unclear and was not explored with YAS.

    Verbatim wording from the response

    “Having reviewed the statements and documents from the attending YAS clinicians, Mr Carroll was reporting suicidal ideations, was a consenting adult and was taken to a hospital Emergency Department, as a place of safety. They further report that Mr Carroll was on his mobile phone throughout the journey and they believed that he was in contact with his brother. Given that this is all the information that was available to you from YAS, it is difficult to understand the evidential basis for your concern, and as this was not”

    Source location

    2016-0384-Response-by-Yorkshire-Ambulance-Service
    Page 1 · response
    Published 27 October 2016

    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

    Existing welfare-assessment and referral practices, including asking about family contact, are considered sufficient to address the concern.

    Verbatim wording from the response

    “Having discussed this matter with a number of colleagues and managers from both the Clinical and Operations Directorates within the Trust, I can confirm that whilst not formalised in any written process, it is standard practice amongst clinicians as part of any welfare assessment of the patient to ask if there is any family member that can be contacted.”

    Source location

    2016-0384-Response-by-Yorkshire-Ambulance-Service
    Page 2 · response
    Published 27 October 2016

    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

    For patients conveyed to hospital, longer-term management and contacting relatives are primarily the receiving hospital's responsibility, not YAS's.

    Verbatim wording from the response

    “If a decision is made to convey a patient such as Mr Carroll to a hospital or other appropriate place of care, there are commonly discussions had with the patient as to whether a family member can be contacted. The next of kin contact details are recorded on the Patient Care Record (PCR) whenever these can be obtained and this is then handed over to the receiving hospital or healthcare organisation on arrival, along with the duty of care to it. It would be expected that a longer term management plan is then put in place by the hospital for the patient prior to discharge which would include making contact with the patient's relatives where appropriate.”

    Source location

    2016-0384-Response-by-Yorkshire-Ambulance-Service
    Page 2 · response
    Published 27 October 2016

    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

    Because Mr Carroll appeared capacitated, was an adult, and had been handed over to professionals, officers had no expectation to notify friends or relatives.

    Verbatim wording from the response

    “As you have noted, officers did not make contact with friends or relatives before Mr Carroll was taken by ambulance to hospital. Given his apparent possession of mental capacity, his adulthood and the handover to other professionals for his onward care, there has previously been no expectation that officers would make such intimations.”

    Source location

    2016-0384-Response-by-North-Yorkshire-Police
    Page 1 · response
    Published 27 October 2016

    Open published response
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Data last updated 7 September 2026