PFD report

Greg HUTCHINS · Prevention of Future Deaths report

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Issued 12 Sep 2018•Warwickshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Failure to retain staff recollection of telephone triage
    Part of recurring concern: Telephone triage that is unreliable and can delay necessary care
  2. Lack of contemporaneous records of telephone triage
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Telephone triage that is unreliable and can delay necessary care
  3. Failure to update the RIO system with telephone triage information
    Part of recurring concern: Telephone triage that is unreliable and can delay necessary carePart of recurring concern: Unreliable RIO clinical-record functions
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 clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to retain staff recollection of telephone triage

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of contemporaneous records of telephone triage

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Telephone triage that is unreliable and can delay necessary care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to update the RIO system with telephone triage information

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care; Unreliable RIO clinical-record functions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of subsequent notes of telephone triage

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care; Unreliable documentation of clinical triage decisions and advice.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clarity about the purpose and scope of telephone triage

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of a national system for rapid information sharing

Wider context from the report

“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026