Emergency family notification
123 items
2 sources
Failure to notify family members about a patient's condition or transfer in emergency situations, causing distress.
Cross-Source Insight
Emergency family notification has been flagged across 2 independent accountability sources:
15 inquiry recs
108 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (15)
BAHA-16 — Death in Custody Checklist
Recommendation: JDP 1-10 should include a simple checklist for actions on a death in custody. Where there is a death in custody, particularly one that is sudden or unexplained, prompt checks must be made on the welfare of other CPErS. The …
Gov response: Accepted. A death in custody checklist has been developed, including scene preservation guidance.
Accepted
Delivered
DM-5 — Separate SIO and Family Liaison Officer roles
Recommendation: The Metropolitan Police should ensure that the role of the Family Liaison Officer is never carried out by the Senior Investigating Officer of an investigation. There is an inherent conflict between these two roles.
Gov response: The new National Major Crime Investigation Manual (MCIM) published in November 2021 covers all aspects of major crime investigation and sets the standard for all forces alongside the relevant Authorised Professional Practice (APP) produced by …
Accepted
Delivered
FENN-153 — Agree common system for casualty identification and fatality documentation in London
Recommendation: A uniform documentation procedure for handling and receiving fatalities should be considered. In London all the services must meanwhile agree a common system for identification of casualties and recording the position in which they are found.
Unknown
IHRD-43 — GP Notification of Death Circumstances
Recommendation: A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Gov response: GP notification procedures established for SAI-related deaths.
Accepted
Delivered
LADB-1 — Computerise system for managing missing persons and casualty information
Recommendation: The system for the reception of information about missing persons, casualties and survivors should be computerised. It should be possible for information which has been received to be entered directly into the computer and for information from it to be …
Unknown
LADB-2 — Extend computerisation to all police forces for shared information access
Recommendation: Computerisation should be extended to all police forces, so that the information collated by each is readily available to all others (para 4.120).
Unknown
LADB-3 — Establish common telephone numbers for public major incident information
Recommendation: The police service, in co-operation with the emergency services, should use their best endeavours to ensure that common telephone numbers are issued for the use of members of the public who are seeking to give or obtain information about persons …
Unknown
LADB-4 — Review railway emergency planning, including survivor after-care and bereaved support
Recommendation: 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).
Unknown
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
MACP-23 — Ensure readily available designated and trained Family Liaison Officers at local level
Recommendation: That Police Services should ensure that at local level there are readily available designated and trained Family Liaison Officers.
Unknown
MACP-24 — Include racism awareness and cultural diversity training for Family Liaison Officers
Recommendation: That training of Family Liaison Officers must include training in racism awareness and cultural diversity, so that families are treated appropriately, professionally, with respect and according to their needs.
Unknown
MACP-25 — Dedicate Family Liaison Officers primarily or exclusively to their liaison task
Recommendation: That Family Liaison Officers shall, where appointed, be dedicated primarily if not exclusively to that task.
Unknown
MACP-26 — Ensure Senior Investigating Officers provide comprehensive information and manage family liaison.
Recommendation: 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 …
Unknown
MACP-27 — Formally record and report all family requests and complaints to superior officers.
Recommendation: 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 …
Unknown
MACP-28 — Proactively use local minority ethnic contacts for family liaison assistance.
Recommendation: That Police Services and Victim Support Services ensure that their systems provide for the pro-active use of local contacts within minority ethnic communities to assist with family liaison where appropriate.
Unknown
PFD Reports (108) — showing 100 most recent
Ernest Gray
Concerns: The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.
Response: East Kent Hospitals has updated their discharge checklist to ensure identification of main carers, developed a care advice leaflet for patients with carers, and implemented a 'carer's passport' and a …
Responded
Joanna Chamberlain
Concerns: A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family and GP input in care plans.
Response: NHS England is trialling neighbourhood mental health centres in six areas to provide community support for mental health patients not in immediate crisis. They have also shared draft 'Personalised Care …
Responded
James Cochrane
Concerns: There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.
Responded
Samantha Young
Concerns: A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.
Responded
Alfie Lydon
Concerns: Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.
Responded
Amy Levy
Concerns: Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Responded
Abdirahman Afrah
Concerns: A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.
Responded
George Fraser
Concerns: The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.
Responded
Robert Smith
Concerns: Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Responded
Bernard Lyon
Concerns: Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.
Responded
Laura Farmer
Concerns: Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was no feedback loop to clinicians, leaving the family without answers or safety guidance.
Responded
Neil Woodley
Concerns: Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns about avoidable fatalities in future cases.
Responded
Andrew Naylor
Concerns: There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug treatment teams hindered safe discharge planning.
Responded
Sally Poynton
Concerns: An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness who declined treatment, created significant care gaps.
Overdue
Kenneth Baylis
Concerns: The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Responded
Rachel Mortimer
Concerns: The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.
Responded
Reece Nelson
Concerns: Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.
Responded
Michael Hindes
Concerns: There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about his mental health.
Responded
Kaye McCoy
Concerns: The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.
Responded
David Wood
Concerns: There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge care, highlighting a need to review discharge protocols following heart surgery.
Responded
Brenda Shields
Concerns: The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.
Responded
Andrew Dean
Concerns: There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about a prisoner's safety, posing a risk of future self-harm or suicide.
Responded
Carol Robinson
Concerns: The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.
Responded
Jai Singh
Concerns: Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.
Responded
Annabel Findlay
Concerns: The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.
Responded
Daniel Lee
Concerns: A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was inadequate, hindering effective risk sharing and support.
Responded
Harry Evans
Concerns: The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.
Responded
Emma Simkin
Concerns: Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.
Responded
Robert Brown
Concerns: “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without essential support.
Overdue
Cassian Curry
Concerns: Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.
Responded
Oliver Lindsay
Concerns: Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.
Responded
Kirsty Doodes
Concerns: Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.
Responded
Joshua Sahota
Concerns: Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.
Responded
Norma Rushworth
Concerns: Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.
Responded
Sheldon Farnell
Concerns: Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Responded
Ben O’Hara
Concerns: Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.
Responded
Grazyna Walczak
Concerns: The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
Responded
Steven Cooke
Concerns: There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.
Overdue
Francis Cooney
Concerns: Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.
Responded
Annette Lewis
Concerns: There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting suicide at this and similar sites.
Overdue
Joanna Orpin
Concerns: Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.
Responded
David Fowler
Concerns: The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
Responded
Sam Spooner
Concerns: A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.
Responded
Charlotte Grace
Concerns: Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.
Responded
Matthew Williamson
Concerns: Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.
Responded
Ceara Thacker
Concerns: Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked training on safe intervention for hangings.
Responded
Iain Macinnes
Concerns: The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.
Overdue
Rebecca Henry
Concerns: Strict patient confidentiality rules frequently impede crucial communication between medical staff and relatives of mental health patients, potentially preventing timely interventions and explanations that could save lives.
Responded
Steffan Kuenzel
Concerns: The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.
Responded
Anthony Buckingham
Concerns: The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.
Responded
Robert Hughes
Concerns: The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.
Responded
Richard Lockley
Concerns: Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.
Responded
Christopher McGuffie
Concerns: Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Responded
Thomas Lear
Concerns: A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.
Pending
Natasha Ednan-Laperouse
Concerns: Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and adrenaline dose were identified as dangerously insufficient for adult anaphylaxis.
Responded
Dudley Brown
Concerns: Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health assessment.
Overdue
Martin Baker
Concerns: Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.
Responded
Ivanika Olivari
Concerns: Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all contact numbers, risking delays in life-critical situations. National guidance needs clarification.
Overdue
Georgia Polydorou
Concerns: Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language barriers and inadequate information sharing with family, further compromise care.
Overdue
Adrian King
Concerns: British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care outcomes.
Responded
Ronald Compson
Concerns: Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about an initial fall.
Responded
Anne Morris
Concerns: Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite consent, and the community team did not proactively seek discharge information.
Responded
Ryan Vout
Concerns: There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.
Responded
Gillian O’Keefe
Concerns: The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.
Responded
Conall Gould
Concerns: The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.
Responded
Barbara Sturgess
Concerns: The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.
Overdue
Melvin James
Concerns: The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.
Overdue
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Rasikaben Chauhan
Concerns: There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.
Responded
Mariana Pinto
Concerns: The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.
Responded
Doreen Stapleton
Concerns: An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.
Responded
Emily Voukelatou
Concerns: The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.
Responded
Georgina Lewis
Concerns: Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.
Overdue
Charles Woodward
Concerns: Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
Overdue
James Flynn
Concerns: Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.
Overdue
Samuel Carroll
Concerns: Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.
Responded
Debrata Sircar
Concerns: A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.
Overdue
Jack Susianta
Concerns: Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Overdue
Monica Lewis-Hinds
Concerns: The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.
Overdue
Mandeep Singh
Concerns: Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Responded
Lisa Day
Concerns: The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in a diabetic.
Responded
Patricia Medland
Concerns: The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.
Responded
Brenda Morris
Concerns: Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.
Responded
Joanne French
Concerns: Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Overdue
Frank Mellers
Concerns: There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies for DNAR issuance and communication require urgent review.
Responded
William Abel
Concerns: Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.
Responded
Julia Hayward
Concerns: Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.
Responded
Margaret Wright
Concerns: Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Responded
Archie Hexall
Concerns: A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.
Responded
Colin Tyson
Concerns: Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.
Responded
Roseanne Cooke
Concerns: Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Pending
Graham Darby
Concerns: A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Overdue
Joshua Brown
Concerns: The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.
Overdue
Silvia Taylor
Concerns: The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential intervention.
Overdue
Marion Turner
Concerns: A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.
Overdue
Alun Sheppard
Concerns: The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Responded
Graham Watts
Concerns: The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Responded
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Responded
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Responded
Christopher Williams
Concerns: A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Overdue