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You are in the PFD Zone

Categories of concerns raised in PFD reports

These are categories I have identified through my own analysis, not categories defined by Coroners.

1.1 Technical issues 1.2 System usage issues 1.3 Data quality issues
1.1.1 Access to data; interoperability issues 1.1.2 System configuration and functionality 1.1.3 NHS and private health providers' systems not connected 1.1.4 No single source of truth
No interoperability between systems – even between systems from the same supplier. Information is therefore kept in separate silos, with no reliable single view of the truth. A recurring problem within the NHS; between the NHS and private healthcare; between prison staff and prison healthcare providers; and between health, local authority social care, and care providers.
Systems are poorly designed and configured, hard to use, not suited to the front line working environment A recurring problem within the NHS; between the NHS and private healthcare; between prison staff and prison healthcare providers; and between health, local authority social care, and care providers
No interoperability between systems – even between systems from the same supplier. Information is therefore kept in separate silos, with no reliable single view of the truth. A recurring problem within the NHS; between the NHS and private healthcare; between prison staff and prison healthcare providers; and between health, local authority social care, and care providers.
No interoperability between systems – even between systems from the same supplier. Information is therefore kept in separate silos, with no reliable single view of the truth. A recurring problem within the NHS; between the NHS and private healthcare; between prison staff and prison healthcare providers; and between health, local authority social care, and care providers.
1.2.1 No information sharing agreement in place 1.2.2 Free text/"needle-haystack syndrome" 1.2.3 Paper records
Even where systems are capable of exchanging data or recording it in a structured way, the capability isn’t properly used Seen in all services, but particularly NHS and criminal justice system
Information is recorded as free text, so can’t be easily located when needed - "needle-haystack syndrome" Seen in all services, but particularly NHS and criminal justice system
An over-reliance on paper records. Seen in all services, but particularly NHS and criminal justice system
1.3.1 Information absent or incomplete 1.3.2 Information inaccurate 1.3.3 Information misleading 1.3.4 Information falsified
Data not recorded or incomplete – one of the top three failures found across all services. May be partly explained (though not excused) by a lack of time or capacity to create accurate records, but the prevalence of the issue suggests it may be deeper rooted than this – a disregard for the importance of timely and accurate record-keeping and/or for the fact that other professionals might rely on that data.
Data inaccurate – may be partly explained (though not excused) by a lack of time or capacity to create accurate records, but the prevalence of the issue suggests it may be deeper rooted than this – a disregard for the importance of timely and accurate record-keeping and/or for the fact that other professionals might rely on that data
Data misleading, often because lacking in context – may be partly explained (though not excused) by a lack of time or capacity to create accurate records, but the prevalence of the issue suggests it may be deeper rooted than this – a disregard for the importance of timely and accurate record-keeping and/or for the fact that other professionals might rely on that data
In a few cases (largely observation records in prisons and secure MH units) data was deliberately falsified. - May be partly explained (though not excused) by a lack of time or capacity to create accurate records, but the prevalence of the issue suggests it may be deeper rooted than this – a disregard for the importance of timely and accurate record-keeping and/or for the fact that other professionals might rely on that data
2.1 Failure to communicate/engage with other professionals 2.2 Failure to communicate/engage with the person or a family member, friend or carer 2.3 Failure of policy, process, practice or professionalism
2.1.1 Professional information ignored on not read 2.1.2 Failure to communicate - internal 2.1.3 Failure to communicate - external (other teams, services, professions) 2.1.4 Failure to communicate - hospital discharge This was the most frequently recurring theme identified in this study.  It occurs across all services, and is the most frequent theme in six out of eight service types
Failure to communicate or engage with other professionals was the most frequently recurring theme identified in this study. It occurs across all services, and is the most frequent theme in six out of eight service types It is a two-way problem, including - failure to share information with other professionals, even where systems are in place to enable it; - failure to have regard to information shared by other professionals. This category includes failure to have regard to information in (e.g.) Education, Health and Care Plans (EHCPs), Individualised Care Plans etc.
Failure to communicate or engage with other professionals was the most frequently recurring theme identified in this study. It occurs across all services, and is the most frequent theme in six out of eight service types It is a two-way problem, including - failure to share information with other professionals, even where systems are in place to enable it; - failure to have regard to information shared by other professionals. This category was visible across the board, but was particularly common in NHS settings, e.g. when information wasn't passed from one shift's staff to the next. Information was sometimes communicated, but with no sense of urgency, and thus not retained or acted on. These were some of the numerous cases where critical information simply wasn’t communicated to those who needed to know it or act on it.
Failure to communicate or engage with other professionals was the most frequently recurring theme identified in this study. It occurs across all services, and is the most frequent theme in six out of eight service types It is a two-way problem, including - failure to share information with other professionals, even where systems are in place to enable it; - failure to have regard to information shared by other professionals. A common theme was prison healthcare staff failing to communicate with prison staff (see Trevor Monerville and Benjamin Harrison’s PFD reports for examples). Other examples include: - Failures to use existing inter-agency arrangements (multi-disciplinary teams, multi-agency risk assessment conferences etc) to raise concerns or co-ordinate action - Time pressure - Fear of sharing information - Lack of clarity about who should report or act on something - Information being communicated, but with no sense of urgency - Lack of contact details for teams in neighbouring areas Above all, numerous cases where critical information simply wasn’t communicated to those who needed to know it or act on it.
Failure to communicate or engage with other professionals was the most frequently recurring theme identified in this study. It occurs across all services, and is the most frequent theme in six out of eight service types It is a two-way problem, including - failure to share information with other professionals, even where systems are in place to enable it; - failure to have regard to information shared by other professionals. This category includes failures to communicate at hospital admission, transfer and discharge – an obvious point of handover of professional responsibility. Specifically, there were several instances of poor handover between ambulance and hospital staff.
2.2.1 Not talking to the person or their family member/friend/carer 2.2.2 Not listening to the person or their family member/friend/carer 2.2.3 Language or other comms barrier; no reasonable adjustments made  2.2.4 Lack of cultural awareness Less frequent than the failure to communicate with other professionals, but no less disturbing.
Less frequent than the failure to communicate with other professionals, but no less disturbing. This category includes both failure to give information to the person and/or their family, and failure to give them information in language they will understand.
Less frequent than the failure to communicate with other professionals, but no less disturbing. The failure to listen was more frequent in NHS mental health teams/units than other services. Coroners were particularly critical of mental health professionals who disregarded “collateral information” offered by friends, family and unpaid carers, often on the grounds that “they aren’t the patient”.
Less frequent than the failure to communicate with other professionals, but no less disturbing. This category specifically covers failure to make reasonable adjustments for communication needs. It reflects the message in a recent report by Healthwatch that NHS England's Accessible Information Standard is not being properly followed - a standard which exists precisely to prevent these problems from arising.
Less frequent than the failure to communicate with other professionals, but no less disturbing. This category focuses on a lack of cultural awareness and/or cultural sensitivity in professionals' dealings with members of the public.
2.3.1 Information not sought; lack of professional curiosity; capacity not considered 2.3.2 GDPR Says No  2.3.3 Cycle of Doom; no multi-disciplinary team; no lead professional 2.3.4 Other failure of policy, process, practice or professionalism
"Failure of policy, process, practice or professionalism" is a catch-all category for issues that relate to communication and information sharing but don’t fall squarely within the previous two categories. A recurring phrase is “lack of clinical curiosity” or “lack of professional curiosity”. This refers to failures to follow up on information received, think through its implications, or consider whether the information is reliable and trustworthy. In a number of cases people’s mental capacity was not given proper consideration, e.g. where an independent advocate could have been involved but wasn’t. There were several instances of a lack of professional leadership or co-ordination across multiple services, where no one professional had (or took) overall responsibility for the person’s care, safety and/or wellbeing. A significant number of cases fell into several categories, but also displayed an overarching lack of basic professionalism – a failure in the fundamental duty of care. This appears to be particularly visible in the criminal justice system.
"Failure of policy, process, practice or professionalism" is a catch-all category for issues that relate to communication and information sharing but don’t fall squarely within the previous two categories. This category refers to cases where professionals were clearly adopting the doctrine of "GDPR Says No" or the common law duty of confidentiality as a reason not to share information, even where organisational policy requires it.
"Failure of policy, process, practice or professionalism" is a catch-all category for issues that relate to communication and information sharing but don’t fall squarely within the previous two categories. There were several instances of a lack of professional leadership or co-ordination across multiple services, where no one professional had (or took) overall responsibility for the person’s care, safety and/or wellbeing.
"Failure of policy, process, practice or professionalism" is a catch-all category for issues that relate to communication and information sharing but don’t fall squarely within the previous two categories. This category includes a significant number of cases which fell into several categories, but also displayed an overarching lack of basic professionalism – a failure in the fundamental duty of care. This appears to be particularly visible in the criminal justice system.
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