Emergency family notification
Failure to notify family members about a patient's condition or transfer in emergency situations, causing distress.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
73match
James Flynn
The coroner identified inadequate discharge planning for an unwell, elderly diabetic patient, who was sent home late without a detailed care plan, family notification, or provisions.
Matched on
terms: family, notification
PFD report
69match
Georgina Lewis
The coroner noted a lack of family notification or consultation in the discharge decision, the absence of a discharge plan or follow-up support, and no contemporaneous notification of the discharge to Mrs Lewis's GP.
Matched on
terms: family, notification
PFD report
69match
Mariana Pinto
The coroner identified insufficient communication to the family about crisis team limitations and anticipated illness progression. An urgent crisis line call did not result in the nurse suggesting or making an emergency call, or considering an earlier home visit.
Matched on
terms: emergency, family
PFD report
65match
Colin Tyson
The coroner noted concerns regarding GPs' interpretation of patient confidentiality, which prevented family members from sharing pertinent information about vulnerable individuals at risk.
Matched on
terms: family
PFD report
65match
Julia Hayward
Care plans for patients discharged into the care of family members following mental health assessments are agreed orally and not documented for the family, leading to uncertainty about responsibilities.
Matched on
terms: family
PFD report
65match
Joanne French
Insufficient clarity and communication regarding early patient discharge assessment requirements were noted, along with unclear documentation. Additionally, there was no process for family members, who would provide care, to input their views or understand the discharge decision.
Matched on
terms: family
PFD report
65match
Emily Voukelatou
The coroner noted that the crisis team did not routinely involve family members in patient care, potentially losing valuable input. Additionally, a patient's family members made repeated unreturned calls to Crisis House, resulting in lost information and increased anxiety.
Matched on
terms: family
IOPC learning recommendation
65match
Police response to notify family of woman’s death – South Yorkshire Police, June 2020
The IOPC recommends that the College of Policing should issue appropriate advice on delivering a death message where the person receiving the message is not in their own home. This should set out a requirement for a dynamic risk assessment to assess their welfare and safety immediately after the message has been given. This follows an IOPC complaint...
Matched on
terms: family
IOPC learning recommendation
65match
National recommendations - National Police Chiefs Council, September 2020
The IOPC recommends that the NPCC lead for complaints and misconduct works with all forces to ensure that requirements around delivering the message about a police-related death are clear and understood. This includes the requirement that the senior officer on duty with responsibility for Professional Standards and liaison with the IOPC should: - recognise the need to provide...
Matched on
terms: family, notification
Scottish FAI
65match
Sharon Harkin
My position in this specific case does not detract from a general expectation that there should be a system in place for early and sensitive notification to a deceased’s family.
Matched on
terms: family, notification
HSSIB recommendation
62match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by listening to and communicating with patients, their families and carers, about the safety and wellbeing of people who have self-harmed and/or are expressing suicidal thoughts. It is important that this involvement starts from the point of a patient’s admission through to their discharge from inpatient mental health wards and during follow up....
Matched on
terms: family
PFD report
61match
Christopher James Morgan
The coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Matched on
terms: family
PFD report
61match
Joshua Brown
The coroner noted limited information sharing with Mr. Brown's parents, his primary support, due to his wishes and their non-carer status, which impacted their ability to assist the team. There was also no system for family members to review and confirm the accuracy of notes made by the community team.
Matched on
terms: family
PFD report
61match
Roseanne Cooke
The coroner noted a lack of inpatient psychological support and confusion regarding outpatient referrals. Concerns were also raised about the Recovery Team's attendance at discharge meetings and insufficient communication of family concerns about the deceased's suicidal thoughts to the team.
Matched on
terms: family
PFD report
61match
Frank Mellers
The coroner noted the patient's DNAR status was fixed without family discussion, contrary to good practice. There was poor communication between nursing and medical staff, leading to a resuscitation attempt despite a DNAR order.
Matched on
terms: family
PFD report
61match
Brenda Morris
The coroner noted insufficient communication with a patient's partner regarding the basis for weekend leave and a lack of routine family feedback post-leave. There were also concerns about confusion over medical authorisation for informal patient leave and substandard nursing documentation.
Matched on
terms: family
PFD report
61match
Charles Woodward
Inadequate communication and liaison between the hospital, GP practice, and district nurses regarding the deceased’s ongoing care post-discharge. Additionally, monitoring of the deceased’s condition from the hospital was not robust enough, and there was miscommunication with the family about the deceased's declining health.
Matched on
terms: family
PFD report
61match
Doreen Stapleton
The coroner noted insufficient emphasis on discharge advice, specifically the lack of explicit communication to the patient and family about the critical importance of follow-up medication and the absence of a contact number for the district nursing team.
Matched on
terms: family
PFD report
61match
Melvin James
The patient was discharged from hospital while still experiencing delusions, with the clinician unaware of the family's observations. There was insufficient communication with the family about relapse symptoms and no formal referral or aftercare arranged with mental health services post-discharge.
Matched on
terms: family
PFD report
61match
Conall Gould
The coroner raises concerns about the lack of clear communication to patients and their carers regarding follow-up mental health appointments after discharge. There is no formal policy or protocol requiring notification or written confirmation of these arrangements, increasing the risk of missed appointments and lost opportunities for patient review.
Matched on
terms: notification
PFD report
61match
Ryan Vout
The coroner identified insufficient co-ordination in discharge planning from inpatient psychiatric care, including a lack of liaison between professionals and family. Concerns were also raised about the inability to pre-arrange ambulances and the informal nature of risk assessments before executing MHA warrants.
Matched on
terms: family
Inquiry recommendation
60match
IHRD-43 - GP Notification of Death Circumstances
A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Matched on
terms: family, notification
PFD report
57match
Graham Watts
The coroner noted significant flaws in Mr. Watts' hospital discharge procedure, including blank paperwork, a lack of communication with his nursing home and family, and his medical unsuitability for discharge. He returned to the nursing home in a deteriorated state.
Matched on
terms: family
PFD report
57match
Terence Dooley
The coroner noted concerns regarding the inappropriate green coding of an emergency overdose call, resulting in a significant delay in ambulance response. Gaps in communication and misleading computer-generated codes were identified as contributing factors.
Matched on
terms: emergency
PFD report
57match
Silvia Taylor
Unsuccessful attempts to contact Mrs. Taylor were not acted upon for several hours, and these difficulties were not conveyed to her family. The coroner suggests reviewing 'no speech call procedures' for after-hours support.
Matched on
terms: family
PFD report
57match
Graham Darby
A specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Matched on
terms: family
PFD report
57match
William Abel
A Mental Health Act assessment was not conducted when Mr. Abel expressed suicidal intention, and there was inadequate communication with his family about his mental health relapse and the expectation for his safe keeping.
Matched on
terms: family
PFD report
57match
Jack Susianta
The consultant psychiatrist did not communicate clear clinical expectations to Jack's family before discharge, including what recurrence of psychotic symptoms would signify and when to seek urgent professional help. This left the family unaware of when immediate re-hospitalisation might be necessary.
Matched on
terms: family
PFD report
57match
Samuel Carroll
Concerns were raised regarding police and ambulance services not seeking Mr Carroll's consent to inform family or friends about his suicidal ideation and hospital admission. Consequently, no one was alerted to him being taken to or discharged from the hospital.
Matched on
terms: family
PFD report
57match
Gillian O’Keefe
The coroner identified an illogical discharge decision despite mental health deterioration, an absence of pre-discharge meetings with the GP, and no policy for urgent GP referrals. Difficulties for the family to communicate concerns were also noted.
Matched on
terms: family
IOPC learning recommendation
57match
Complaints raised by family after recovery of young teenager's body - South Wales Police, 2019
The IOPC recommends that South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers/staff when dealing with bereaved families. There should be clear agreement in advance about what information can be shared with a family, and a record made of the information provided. In addition, any questions asked by...
Matched on
terms: family
PHSO casework decision
56match
P-003374 - James Paget University Hospitals NHS Foundation Trust
Mrs A complained a consultant nephrologist failed to communicate effectively and discuss treatment options with her family during her husband's final hours, causing immense distress.
Matched on
terms: family
PFD report
53match
Noel Williams
The coroner noted a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, which was important for assessing the patient's fitness for surgery. This gap in communication could lead to future deaths.
Matched on
classifier match
PFD report
53match
Charles Bradley
The coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Matched on
classifier match
PPO recommendation
53match
The Governor of HMP Lancaster Farms
The Governor should ensure that a family liaison officer is appointed when a prisoner becomes seriously ill and that appropriate arrangements are made to ensure early contact with families.
Matched on
terms: family
IOPC learning recommendation
53match
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police introduce a policy/practice which ensures an officer of designated rank (the IOPC suggests Inspector or above) has overall responsibility for identifying Next of Kin and ensuring appropriate delivery of the death message, in police shooting related deaths. On this occasion, it took almost 12 hours for the deceased’s family to be...
Matched on
terms: family
Inquiry recommendation
53match
LADB-4 - Review railway emergency planning, including survivor after-care and bereaved support
The Railway Group should review emergency planning, including liaison with the emergency services, arrangements for the after-care of survivors and the provision of support and facilities for the bereaved and injured (para 4.122).
Matched on
terms: emergency
Inquiry recommendation
53match
MACP-26 - Ensure Senior Investigating Officers provide comprehensive information and manage family liaison.
That Senior Investigating Officers and Family Liaison Officers be made aware that good practice and their positive duty shall be the satisfactory management of family liaison, together with the provision to a victim's family of all possible information about the crime and its investigation.
Matched on
terms: family
Inquiry recommendation
53match
MACP-23 - Ensure readily available designated and trained Family Liaison Officers at local level
That Police Services should ensure that at local level there are readily available designated and trained Family Liaison Officers.
Matched on
terms: family
PPO recommendation
52match
The Governor of HMP Risley
The Governor should appoint a family liaison officer as soon as a prisoner becomes seriously ill, to enable timely contact with the next of kin or other family members in accordance with PSU 64/2011.
Matched on
terms: family
Inquiry recommendation
52match
MACP-27 - Formally record and report all family requests and complaints to superior officers.
That good practice shall provide that any request made by the family of a victim which is not acceded to, and any complaint by any member of the family, shall be formally recorded by the SIO and shall be reported to the immediate superior officer.
Matched on
terms: family
PHSO casework decision
51match
P-003448 - East Sussex Healthcare NHS Trust
Miss B and Mrs B complained a nurse administered wrong medication, and the Trust delayed notifying the family of Mr B's deterioration, causing distress and affecting their grieving process.
Matched on
terms: family
PFD report
49match
Derek Edward Bartlett Twivey
The coroner noted that a falls risk assessment for a patient with a known high falls risk was not conducted within the anticipated 24 hours of arrival at a nursing home, due to it being a weekend and staffing pressures.
Matched on
classifier match
PFD report
49match
Robert Jones
The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Matched on
classifier match
PFD report
49match
Caroline Pilkington
North West Ambulance Service personnel are not trained in control and restraint techniques, leading to calls for police assistance with unwell patients. This can result in clinically unwell patients being handled by non-clinically trained police and delays in hospital transport.
Matched on
classifier match
PFD report
49match
Alun Sheppard
The coroner raised concerns regarding the Health Board's ability to balance a patient's right to confidentiality with the potential benefits of facilitating familial support to optimize recovery.
Matched on
classifier match
PFD report
49match
Marion Turner
A message from Ms Turner's solicitor about her mental health concerns was left for her CPN but remained unread until the next day, indicating a delay in processing important patient information.
Matched on
classifier match
PFD report
49match
Archie Hexall
The coroner noted a breakdown in communication between midwives regarding signs of respiratory distress, and the initial observation records were not retained. Parents were also not informed of concerns about their child's breathing, limiting their opportunity to contribute to care.
Matched on
classifier match
PFD report
49match
Margaret Wright
The coroner noted that doctors did not routinely telephone patients or their families when a home visit was requested to obtain further information, which could have led to a priority visit in this case. A system for pre-visit telephone contact has since been introduced and should be drawn to the attention of the Secretary of State for Health.
Matched on
classifier match
PFD report
49match
Edna Cleaton
The practice lacked systems to ensure patients on citalopram received appropriate medical reviews every 3-6 months, as one patient went over 3 years without review, potentially missing signs of deterioration.
Matched on
classifier match