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2.1.3. Failure to communicate - external (other teams, services, professions, organisations)
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.
PFD reports citing this issue
sent to
Other NHS primary care (not GP)
Zee had been prescribed four medications to help with his mental health needs. He stopped taking two of them because of the side-effects, and told the mental health team, butthey didn't tell his GP who had prescribed the medication. The effect of his stopping the medications without proper care and supervision contributed to his suicide.
sent to
MH unit (inc for people detained under MH Act)
"Danny took his own life, whilst suffering from a mental illness, and whilst receiving absolutely no care from the mental health services. Danny’s death was contributed to by cumulative failures, amounting to a gross failure, to provide mental health care to him."
The MH unit discharged Danny unsafely - no discharge info provided, no regard given to the environment he needed post-discharge, no s.117 aftercare sought or put in place.
The Community MH team failed to follow up on Danny's own statements; failed to communicate with the housing service or the GP about either Danny's needs or their own (lack of) actions; and failed to show any clinical curiosity about Danny's condition.
sent to
MH team (community healthcare trust)
"Danny took his own life, whilst suffering from a mental illness, and whilst receiving absolutely no care from the mental health services. Danny’s death was contributed to by cumulative failures, amounting to a gross failure, to provide mental health care to him."
The MH unit discharged Danny unsafely - no discharge info provided, no regard given to the environment he needed post-discharge, no s.117 aftercare sought or put in place.
The Community MH team failed to follow up on Danny's own statements; failed to communicate with the housing service or the GP about either Danny's needs or their own (lack of) actions; and failed to show any clinical curiosity about Danny's condition.
sent to
Local authority: Children's Services (inc social care and education/SEND)
Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance.
The Coroner identified failures by Surrey County Council including:
a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services.
b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently.
c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently.
d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family
e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan.
f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family.
g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family.
h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks
i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken.
There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.
sent to
MH team (community healthcare trust)
Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease
sent to
Healthcare staff in prison setting (inc MH)
Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others.
Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.
sent to
Early Years setting, school, college or university
(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down?
(2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did.
sent to
GP practice
(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down?
(2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did.
sent to
Any other locally commissioned/provided NHS service
Susan was a resident in a care home who develo-ped pressure ulcers. She was under the care of District Nurses, who asked a GP and the tissue viability team for input, but they were shown out-of-date photographs and didn't appreciate the extent of her deterioration. As a result Susan wasn't precribed antibiotics when she should have been. She deteriorated rapidly and was admitted to hospital, where she died two months later.
The DNs also failed to share information with the care team or Susan's family.
sent to
Ambulance Service
Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address.
Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk.
Shortcomings in software and communication systems amongst agencies.
Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.
sent to
Police force(s)
Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address.
Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk.
Shortcomings in software and communication systems amongst agencies.
Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.
sent to
Private sector healthcare provider commissioned by NHS
Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home.
Lack of system integration or clinical communication between the commissioning MH trust and The Priory
Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.
sent to
MH team (community healthcare trust)
Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home.
Lack of system integration or clinical communication between the commissioning MH trust and The Priory
Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.
sent to
Any other locally commissioned/provided NHS service
"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."
sent to
MH team (community healthcare trust)
"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."
sent to
Private sector healthcare provider commissioned by NHS
"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."
sent to
GP practice
"Multiple pieces of relevant information regarding [REDACTED] current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.
"I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS."
sent to
Any other locally commissioned/provided NHS service
"Multiple pieces of relevant information regarding [REDACTED] current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.
"I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS."
sent to
Local authority: Adult Social Care
Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances."
A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs.
Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.
sent to
MH unit (inc for people detained under MH Act)
Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances."
A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs.
Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.
sent to
Domiciliary care provider
Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances."
A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs.
Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.
sent to
MH unit (inc for people detained under MH Act)
Rachel was discharged from an informal admission to a MH unit with too much medication. Her GP record stated that she was at risk of stockpiling and overdosing on pain relief, but she was sent home with 14 days' supply rather than 7.
The Coroner noted that the practice of emailing the GP to notify what medication had been dispensed at discharge, was a point of weakness in the system.
sent to
Any other locally commissioned/provided NHS service
Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody.
(The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.)
The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.
sent to
Police force(s)
Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody.
(The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.)
The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.
sent to
Local authority: Adult Social Care
Owen was a 19yo with severe learning disabilities. He also suffered from Pica (an eating disorder characterised by a tendency to eat non-edible substances).
Owen's carer repeatedly raised concerns about him eating twigs, leaves and blue paper towels with his social worker and school. Despite this, Owen was left unsupervised and died after choking on blue paper towel.
sent to
Healthcare staff in prison setting (inc MH)
Benjamin died in prison due to toxicity from prescribed medication.
“In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared.
“Some healthcare staff in evidence indicated they would not share information about medication in any circumstances.
“The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner’s consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm.”
sent to
MH team (community healthcare trust)
(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically. That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information.
The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed.
There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care- co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendances at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.
sent to
Police force(s)
(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically. That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information.
The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed.
There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care- co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendances at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.
sent to
Any other nationally commissioned/provided NHS service
"During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death."
sent to
Healthcare staff in prison setting (inc MH)
"During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death."
sent to
GP practice
The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not.
In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.
sent to
Hospitals and other NHS acute settings
The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not.
In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.
sent to
Private sector healthcare provider commissioned by NHS
Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment.
There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.
sent to
MH team (community healthcare trust)
Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment.
There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.
sent to
Hospitals and other NHS acute settings
"The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk.
"The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place."
sent to
Domiciliary care provider
Evidence was given that:
Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024.
At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.
None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.
The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.
None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users.
There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.
sent to
MH team (community healthcare trust)
Tom sought help for depression, stating that he had suicidal thoughts. He was assessed by the MH team, but the assessment wasn't properly recorded; no discharge letter was sent to the GP, meaning that Tom didn't get the medication he needed.
"It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care."
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