Recurring concern

Unreliable governance and accountability of multidisciplinary team decisions

First to latest report 26 May 2017 — 22 Dec 2025

Reports that mention this concern
9
Times this concern has been raised
10
Stated actions linked to this concern
3

What this concern includes

Includes failures of governance and accountability controls specifically dedicated to multidisciplinary team decisions, including safeguards against inappropriate unilateral override, clear allocation of decision ownership and leadership, defined thresholds for MDT consideration or escalation, and mechanisms to review or challenge departures from MDT decisions. Includes the anchor and comparable failures concerning absent ownership or unclear discussion thresholds.

What is not included
  • Excludes generic failures of multidisciplinary meeting attendance, discussion quality or patient participation where decision governance and accountability are not the shared unsafe condition; these belong to a broader meeting-operation concern.
  • Excludes failures to implement or follow an MDT recommendation after the decision has been reliably made where decision governance itself is not deficient.
  • Excludes generic clinical governance, senior oversight or individual clinical decision-making failures that do not concern governance of a multidisciplinary team decision.
  • Excludes referral completion, information relay or record-keeping failures unless they directly undermine the governance, ownership or authorised review of an MDT decision.

Reports and published responses 9 reports

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

  1. Manchester South

    AI-generated summary

    Winifred Mary Wardle · 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

    Winifred Mary Wardle was admitted to hospital with vomiting and an undiagnosed intestinal problem; an incarcerated hernia was identified by CT scan after delays in obtaining the scan. She underwent surgery, aspirated stomach contents immediately beforehand, developed pneumonia, and died after active treatment was withdrawn. The substantive concerns related to the lack of a clear multidisciplinary protocol for CT scan requests, radiology decision-making and escalation processes, and incomplete records of those decisions.

    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 clear multidisciplinary protocol for CT scan requests

    Wider context from the report

    “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests; (2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis; (3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants; and (4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account. ”

    Source location

    Winifred Mary Wardle · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    David Paul Power · 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

    David Paul Power, aged 28, intentionally took his own life by hanging on 7 August 2023 after a decline in his mental health. The report found that his deterioration was exacerbated by a letter incorrectly discharging him from a neighbourhood mental health team. Concerns included differing definitions of “stability” between services, which prevented access to talking therapies, and a lack of evidence that subsequent team actions had been embedded or audited.

    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 evidence that SPOE referral for MDT consideration is embedded in team practice

    Wider context from the report

    “6. I heard evidence that since David’s death, the HTT has emailed at the staff at the Tameside HTT to re-iterate the importance of referring cases to SPOE meetings for MDT consideration, and that this has been discussed in two team meetings before February 2024. There was no evidence before me of whether this has been embedded or audited within the team to reduce the risk of future deaths. ”

    Source location

    David Paul Power · Prevention of Future Deaths report
    Page 3 · 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 Home Treatment Team referral and discharge processes requiring onward-referral outcomes and care pathways to be discussed before discharge.

    Verbatim wording from the response

    “‘If the service user requires a referral to other community services such as Living well, and talking therapies, then the practitioner must complete a referral form online and send to appropriate service. This will then be discussed the week after, during their daily huddles, where they discuss each patient who has been referred and their suitability. Patients are not to be discharged from HTT until the outcome of the referral has been discussed and agreed. For service users where a longer term and/or complex care has been indicated, the practitioner can refer to the single point of entry meeting with the corresponding CMHT; this consists of various practitioners and the sector Consultant based on the patient’s GP location.’”

    Source location

    Response from Pennine Care Trust
    Page 4 · response
    Published 18 September 2024

    Open published response

  3. Berkshire

    AI-generated summary

    Mohamed Ahmed Hany Ellaboudy · 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

    Mohamed Ahmed Hany Ellaboudy, known as Moh, died after deliberately placing himself in front of a moving train; his mental state and capacity to form intention were unclear. The report raised concerns about care coordination after discharge from mental health services, reliance on telephone rather than face-to-face appointments, the regularity of multidisciplinary discussions, routes for family to report concerns, and correspondence with primary 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

    Unclear regularity and thresholds for MDT discussions

    Wider context from the report

    “3. Regularity / thresholds for MDT discussions. ”

    Source location

    Mohamed Ahmed Hany Ellaboudy · 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

    Discussing every patient weekly in multidisciplinary meetings is not feasible because of high caseloads, so risk-based thresholds and prioritisation apply.

    Verbatim wording from the response

    “MDT (Multi-Disciplinary Team) meetings occur weekly within the Community Mental Health Teams and are open to all staff to discuss concerns, complex cases, risk, safeguarding concerns, and discharges. These meetings are structured to ensure comprehensive review and coordination of patient care. The threshold for discussing cases in MDTs includes any significant change in a patient's condition, risk factors, or treatment plan. Additionally, any concerns raised by family members or primary care providers can be brought to these meetings for discussion. This priority system is in place as it is not feasible to discuss every patient every week due the high number of patients being held on caseloads. There is documented standard work for our MDT meetings which sets out the criteria for which cases should be brought to this meeting.”

    Source location

    Response from Berkshire Healthcare NHS Trust
    Page 2 · response
    Published 9 May 2024

    Open published response

  4. Worcestershire

    AI-generated summary

    Charlotte Comer · 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

    Charlotte Comer, who had significant mental health disorders and a history of suicide attempts and self-harm, left hospital before treatment for a self-inflicted arm wound and later took a substantial overdose of Propranolol and Amlodipine. She died on 20 July 2021 despite treatment. The principal concerns were instability and excessive workloads in the care coordinator system, including a five-month period without an appointed coordinator, and the failure to prevent a senior clinician from overriding a multidisciplinary team decision about specialist treatment.

    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

    Insufficiently robust safeguards against overriding MDT decisions

    Wider context from the report

    “(2) The erroneous decision to pause Charlotte’s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate. When asked about how the senior clinician could have overridden the MDT decision, the Trust’s Community Services manager for the Worcestershire Neighbourhood Teams told the inquest that he could not say whether the senior clinician was not aware of the correct decision-making procedure, or whether she was, but chose instead to ignore it. When asked whether the same issue could arise in future, he told the inquest that he himself would be in a position to prevent the senior clinician making the wrong decision, but could not guarantee that he would be made aware of the issue so as to be able to do so. I am concerned that the Trust has not properly established how the senior clinician was able to override the MDT decision, and does not have a sufficiently robust system in place to ensure that MDT decisions cannot be overridden in this way in future. ”

    Source location

    Charlotte Comer · 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 to establish how a senior clinician was able to override an MDT decision

    Wider context from the report

    “(2) The erroneous decision to pause Charlotte’s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate. When asked about how the senior clinician could have overridden the MDT decision, the Trust’s Community Services manager for the Worcestershire Neighbourhood Teams told the inquest that he could not say whether the senior clinician was not aware of the correct decision-making procedure, or whether she was, but chose instead to ignore it. When asked whether the same issue could arise in future, he told the inquest that he himself would be in a position to prevent the senior clinician making the wrong decision, but could not guarantee that he would be made aware of the issue so as to be able to do so. I am concerned that the Trust has not properly established how the senior clinician was able to override the MDT decision, and does not have a sufficiently robust system in place to ensure that MDT decisions cannot be overridden in this way in future. ”

    Source location

    Charlotte Comer · 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

    Establish mandatory multidisciplinary governance for specialist-service funding decisions, changes, recording, challenge and escalation.

    Verbatim wording from the response

    “The Trust fully accepts that a lead clinician sought to cancel Charlotte’s Priory referral in error. Evidence of this human error was reflected in the original Root Cause Analysis (RCA) and, consequently, actions have been put in place for a new process for funding arrangements.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 2 · response
    Published 21 March 2023

    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 revised MDT funding decision process is considered sufficient to prevent clinicians from unilaterally overriding specialist referral decisions.

    Verbatim wording from the response

    “Any decisions regarding funding arrangements for specialist services are now established at weekly MDT meetings. Any proposed change to an application must therefore also be brought to a subsequent MDT meeting, and any clinician wishing to challenge or change the MDT decision must be present to make their case. Each decision or change, and the rationale for it, must be clearly and contemporaneously recorded in the patient’s clinical notes. This process ensures mandatory open discussion in a recorded forum (MDT) as a precondition for any change. If the MDT is unable to come to a consensus, the issue will be escalated to the Associate Director (or Deputy Associate Director in their absence) and the Associate Medical Director for a decision.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 3 · response
    Published 21 March 2023

    Open published response

  5. Essex

    AI-generated summary

    Benjamin Lee Stroud · 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

    Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.

    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

    Reliance on a Care Coordinator to make clinical decisions about MDT referral

    Wider context from the report

    “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death. On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring. ”

    Source location

    Benjamin Lee Stroud · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Cornwall and Isles of Scilly

    AI-generated summary

    Dylan Jay Henty · 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

    Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.

    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 escalation of absconding incidents to MDT review

    Wider context from the report

    “iv. There appeared to have been inconsistency in the reporting of incidents of absconding. You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC. Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level, for example, to consider whether current residential arrangements continue to be appropriate. ”

    Source location

    Dylan Jay Henty · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Inform the multidisciplinary team or make referrals after absconding incidents and conduct six-weekly or more frequent monitoring visits with placement review where needed.

    Verbatim wording from the response

    “6. Dependent on the level and frequency of absontion the intention and the risk. The appropriate placement of the home would be assessed. The MDT would immediately be informed in the event of any absobtion, if there are relevant teams in place, if not a referral is made. Reviews and monitoring visits take place 6 weekly or more frequent if needed by the care home. The placement of the home is reviewed in these visits if needed and where appropriate.”

    Source location

    2019-0334-Response-by-Pentree-Lodge-Care-Home
    Page 2 · response
    Published 10 November 2019

    Open published response

  7. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Gerwyn James Thomas · 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

    Gerwyn James Thomas was admitted to hospital after a domestic fall that caused a fractured femur and required surgery. He later developed an infection and died after being readmitted to hospital three times; the inquest recorded sepsis, multi-organ failure and infected hip surgery as the medical cause of death. Concerns included delays in responding to acute dietetic referrals, insufficient staffing, and inadequate training in nutritional assessment.

    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 discuss disputed acute dietetic referrals at a multidisciplinary team meeting

    Wider context from the report

    “3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”

    Source location

    Gerwyn James Thomas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Manchester South

    AI-generated summary

    Aniyah Jasmine Winston · 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

    Aniyah Jasmine Winston was delivered vaginally in an undetected breech presentation and was in poor condition at birth after manipulation during delivery. Resuscitation was commenced and ceased at 10:59am. The concerns included the challenges of undetected breech births and the administration of Syntocinon without further review, examination, counselling or a written prescription; professionals involved reportedly felt unable to challenge the decision.

    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 multidisciplinary team members to challenge incorrect clinical decisions

    Wider context from the report

    “2. The inquest was told by a number of medical professionals involved in Aniyah's birth that they whilst they felt the decision to give Syntocinon was incorrect they did not feel comfortable challenging the decision. The expert instructed was clear that at the time it was given it should not have been. The Trust has since the death of Aniyah put in place a detailed programme to improve confidence in challenging decision-making within a MDT setting. However the extent of recognition of the issue and steps to counter it nationally were unclear. ”

    Source location

    Aniyah Jasmine Winston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Wiltshire and Swindon

    AI-generated summary

    Doreen Helen 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

    Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

    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 individual ownership and leadership for MDT decisions

    Wider context from the report

    “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made. I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken. ”

    Source location

    Doreen Helen MILLER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026