PFD report

Owen Donald GARDNER · Prevention of Future Deaths report

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Issued 15 Jul 2024•Suffolk

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
6

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 raised2

  1. Failure to consistently inform agreed next-of-kin contacts of appointments
    Part of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
  2. Lack of a system for notifying chosen contacts of short-notice appointment changes
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 recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Ensure future assessments consider short-term memory difficulties and record communication preferences in combined assessments, recovery plans and safety plans.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
  2. Action

    Develop and assess a Lorenzo enhancement for sending appointment correspondence to nominated next of kin or carers according to patient preference.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
  3. Action

    Update the community services standard operating procedure with Lorenzo guidance and expectations for recording communication preferences in care documentation.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The new electronic patient record is delayed because procurement must follow the nationally mandated purchasing route.

    Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 consistently inform agreed next-of-kin contacts of appointments

Wider context from the report

“In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered. As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care. Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion. In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact. This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend. It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome. However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment. Evidence was heard that there is no system in place to facilitate this. ”

Is this part of a recurring concern?

Yes — Unreliable arrangement and communication of patient appointments and follow-up.

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 a system for notifying chosen contacts of short-notice appointment changes

Wider context from the report

“In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered. As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care. Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion. In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact. This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend. It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome. However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment. Evidence was heard that there is no system in place to facilitate this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Ensure future assessments consider short-term memory difficulties and record communication preferences in combined assessments, recovery plans and safety plans.

Verbatim wording from the response

“The outcome from this meeting was that the EPR system enhancement noted at paragraph 2 will be helpful and the team, mutually ensure that all future assessments will include consideration of possible short term memory difficulties and confirmation of communication preferences which will be recorded in the combined assessment/recovery plan and safety plans.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

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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

Develop and assess a Lorenzo enhancement for sending appointment correspondence to nominated next of kin or carers according to patient preference.

Verbatim wording from the response

“2. In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have identified a potential enhancement that will allow staff to indicate, when generating correspondence (including appointments) that the correspondence should also be sent to the Next of Kin or Carer, according to stated patient preference.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

Open published response

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

Update the community services standard operating procedure with Lorenzo guidance and expectations for recording communication preferences in care documentation.

Verbatim wording from the response

“4. In addition, our community services standard operating procedure will be updated to include the guidance on the enhanced changes to Lorenzo, along with confirmation of the expectation that communication preferences will be noted in the service user care plan/combined assessment for ease of reference when communicating with service users and those supporting them.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

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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

Continue the Think Carer and Family programme to improve consistent recording of carers and next of kin, including Trust-wide rollout from October 2025.

Verbatim wording from the response

“5. The Trust had also initiated a Listening into Action™ pioneer programme called Think Carer and Family. The Listening into Action™ programme approach is a comprehensive, systemic, outcome-oriented approach to empower staff at all levels to work through any challenges to ensure quality outcomes. In order to bring greater consistency to recording next of kin details to ensure that the technical improvement and system expectation mentioned in the above paragraphs can be meaningfully applied, the aim of the Think Carer and Family LiA programme which was launched on 10 June 2024 is to have 90% of carers and 100% of Next of Kin documented on service users’ records. Initially within Child and Adolescent Mental Health Team, West Suffolk, and Adult Crisis and Resolution Home Treatment Team, West Suffolk, rolling out to the rest of the trust from October 2025.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

Open published response

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

Issue a patient safety alert keeping communication with next of kin and carers a primary staff focus during system changes.

Verbatim wording from the response

“3. The Trust has also issued a patient safety alert to ensure the process remains a primary focus for our staff while this work is completed. This is attached for information.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

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 new electronic patient record is delayed because procurement must follow the nationally mandated purchasing route.

Verbatim wording from the response

“1. The Trust is in the process of procuring a new Electronic Patient Record (EPR) which includes ‘patient portal’ functionality that will enhance our capabilities for appointment scheduling, particularly in terms of visibility for patients. This new EPR is approximately two years from being”

Source location

Response from Norfolk and Suffolk NHS
Page 1 · response
Published 30 July 2024

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 proposed Lorenzo enhancement cannot be implemented until clinical safety and information governance compliance are confirmed.

Verbatim wording from the response

“2. In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have identified a potential enhancement that will allow staff to indicate, when generating correspondence (including appointments) that the correspondence should also be sent to the Next of Kin or Carer, according to stated patient preference.”

Source location

Response from Norfolk and Suffolk NHS
Page 2 · response
Published 30 July 2024

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

No single technical solution can fully mitigate appointment communication risk; mitigation requires a range of actions.

Verbatim wording from the response

“It is most often the case that routine appointments are communicated by letter however urgent or cancellation appointment offers may be made via text, email or through telephone calls based on the agreed method and timeframe to the appointment. This means there is no one single technical solution that will fully mitigate the risk but a range of actions.”

Source location

Response from Norfolk and Suffolk NHS
Page 1 · response
Published 30 July 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue procuring an Electronic Patient Record with patient-portal functionality to improve appointment scheduling visibility.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.

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

Continue procuring an Electronic Patient Record with patient-portal functionality to improve appointment scheduling visibility.

Verbatim wording from the response

“1. The Trust is in the process of procuring a new Electronic Patient Record (EPR) which includes ‘patient portal’ functionality that will enhance our capabilities for appointment scheduling, particularly in terms of visibility for patients. This new EPR is approximately two years from being”

Source location

Response from Norfolk and Suffolk NHS
Page 1 · response
Published 30 July 2024

Open published response
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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