First reported 7 Jan 2014•Latest report 2 Feb 2026
Definition
What this concern includes
Includes failures in the end-to-end end-of-life care decision process, including consultation with treating clinicians, patients, families or appropriate representatives; consideration of treatment history and alternatives; best-interests or contingency discussions; and staff understanding or application of end-of-life care policies and guidance when these controls affect the decision.
Not included
Excludes general communication, consultation or shared-decision-making failures that are not specifically tied to an end-of-life care decision or transition.
Excludes failures in delivery of end-of-life treatment after a safe and adequately informed decision has been made.
Excludes generic palliative-care staffing, service-access or resource deficiencies unless they directly impair the end-of-life care decision and consultation process.
Excludes ordinary disagreement with an end-of-life decision where the decision was adequately informed, consulted upon and governed.
Reports
10
Distinct published reports
Individual concerns
15
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
16
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.
Department of Health and Social Care3
Care Quality Commission2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Agrade Community Care Services Limited1
Care Inspectorate Wales1
Caron Group Ltd1
Crosfield House Limited1
East Suffolk and North Essex NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
NHS Wales1
Stockport Borough Council1
Surrey and Sussex Healthcare NHS Trust1
Walsall Manor Hospital1
NHS trust4
Ministerial department3
Health and social care service regulator2
Health-system partnership2
Domiciliary care provider1
English metropolitan district council1
Healthcare site1
Multi-service care provider1
Private limited company1
Social care inspectorate1
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.
Essex
Concerns raised2
Insufficient familiarity among clinical and nursing staff with palliative and end-of-life care policies and guidance
Failure to communicate and consult effectively with patients and families about end-of-life care decisions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.9
Action
Deliver Trust-wide multidisciplinary education on recognising dying, communication, mental capacity assessments and lasting power of attorney.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Amend palliative care guidance to clarify decision-making authority, commencement of end-of-life care and use of the individualised last-days-of-life care plan.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Complete and distribute a standalone last-days-of-life guide covering recognition of dying, sensitive communication and commencement of the individualised care plan.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Align end-of-life-care e-learning with updated policy and new last-days-of-life guidance, including Epic processes and communication requirements.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Deliver ongoing education on mental capacity, best-interest decisions, communication, ReSPECT, What Matters to Me, escalation and end-of-life documentation.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Embed ReSPECT documentation in the Epic patient dashboard for access, completion and reference during care planning.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Add the What Matters to Me form to Epic to support personalised care planning and recording of patient priorities.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Provide patients and families with a Last Days of Life leaflet during initial end-of-life-care planning and discussions.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Deliver advanced communication training for senior nurses and mental capacity and deprivation-of-liberty training for staff.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Surrey
Concerns raised2
Failure to consult clinicians who had been treating the patient before placing her on end of life care
Failure to consult the Intensive Care team when assessing suitability for intensive care before placing a patient on end of life care
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.
Manchester South
Concerns raised1
Failure to hold formal best interests meetings for key inpatient decisions
This report raised 10 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Audit use of Best Interest Meetings following the October 2019 launch of Trust guidelines.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 January 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A formal best-interests meeting is not a statutory duty, although decision-makers must comply with the Mental Capacity Act consultation requirements.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised3
Failure to discuss End of Life Care with an IMCA
Failure to assess the appropriate care if the patient rallied during End of Life Care
Failure to hold a best interests meeting for End of Life Care
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The local NHS is expected to reflect on the LeDeR findings and address identified local failings in care.
Stated by Helen Whatley MPRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A formal best-interests meeting is not legally required; decision-makers must consult appropriate people where practicable and appropriate.
Stated by Helen Whatley MPDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised2
Failure to fully involve families in palliative care or DNAR decision-making
Failure to provide families with sufficient information about palliative care or DNAR decisions
This report raised 8 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Write to the GP outlining expectations for timely attendance, transparency, contemporaneous records, documented management discussions, DNACPR decisions, and relevant GMC guidance.
Stated by Powys Teaching Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing GMC guidance is considered sufficient for doctors’ capacity and DNACPR decisions, so a separate policy is not needed.
Stated by Powys Teaching Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to hold a community MDT when prescribing end of life medications
This report raised 2 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 A position is what a respondent says about the concern when they do not describe a specific action.2
Position
CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised1
Failure to consult all of a patient’s daughters about care decisions
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.
Black Country
Concerns raised1
Failure to communicate DNAR decisions to the patient’s family
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review the DNAR policy for compliance with best practice, including communication requirements.
Stated by Walsall Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2015.
Action
Develop a leaflet giving patients and families information about DNAR decisions.
Stated by Walsall Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2015.
Action
Conduct peer audits of DNAR form use and continue reviewing them on a rolling basis to assure implementation of disseminated learning.
Stated by Walsall Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 November 2015.
Manchester South
Concerns raised1
Failure to ensure full and meaningful discussion before initiating the End-of-Life Care Pathway
This report raised 12 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review and update the DNACPR policy to require clear, accurate communication and discussion with patients or those close to them.
Stated by Tameside General HospitalStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
Action
Create and disseminate a DNACPR policy DVD through the Trust intranet and staff screen savers.
Stated by Tameside General HospitalStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
Manchester South
Concerns raised1
Failure to involve or update the family about DNAR decisions
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.
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Includes failures in the end-to-end end-of-life care decision process, including consultation with treating clinicians, patients, families or appropriate representatives; consideration of treatment history and alternatives; best-interests or contingency discussions; and staff understanding or application of end-of-life care policies and guidance when these controls affect the decision.
