Emergency family notification
Failure to notify family members about a patient's condition or transfer in emergency situations, causing distress.
255 items
12 sources
7 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Georgina Lewis
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.
Matched on
terms: family, notification
PFD report
73match
James Flynn
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.
Matched on
terms: family, notification
PFD report
73match
Mariana Pinto
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.
Matched on
terms: emergency, family
PFD report
65match
Colin Tyson
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.
Matched on
terms: family
PFD report
65match
William Abel
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.
Matched on
terms: family
PFD report
65match
Joanne French
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.
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
PFD report
61match
Christopher James Morgan
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Matched on
terms: family
PFD report
61match
Graham Watts
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.
Matched on
terms: family
PFD report
61match
Joshua Brown
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.
Matched on
terms: family
PFD report
61match
Roseanne Cooke
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.
Matched on
terms: family
PFD report
61match
Julia Hayward
Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.
Matched on
terms: family
PFD report
61match
Frank Mellers
The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite the DNAR, and guidelines for DNAR communication may need examination.
Matched on
terms: family
PFD report
61match
Brenda Morris
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.
Matched on
terms: family
PFD report
61match
Samuel Carroll
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.
Matched on
terms: family
PFD report
61match
Charles Woodward
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.
Matched on
terms: family
PFD report
61match
Emily Voukelatou
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.
Matched on
terms: family
PFD report
61match
Doreen Stapleton
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.
Matched on
terms: family
PFD report
61match
Melvin James
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.
Matched on
terms: family
PFD report
61match
Gillian O’Keefe
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.
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
Charles Bradley
Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Matched on
classifier match
PFD report
57match
Silvia Taylor
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.
Matched on
terms: family
PFD report
57match
Jack Susianta
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.
Matched on
terms: family
PFD report
57match
John Ramsden
Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Matched on
terms: family
PFD report
57match
Ryan Vout
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.
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
PFD report
53match
Noel Williams
The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
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
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
PFD report
49match
Clive Gould
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Matched on
classifier match
PFD report
49match
Daniel Maurice McMahon
The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending the rule book to require trains to stop when a potentially unwell person is trespassing; and reviewing guidance on lung decompression needles for the ambulance service.
Matched on
classifier match
PFD report
49match
James Stokoe
Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.
Matched on
classifier match
PFD report
49match
Jean James
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Matched on
classifier match
PFD report
49match
Caroline Pilkington
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.
Matched on
classifier match
PFD report
49match
Alun Sheppard
The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Matched on
classifier match
PFD report
49match
Graham Darby
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.
Matched on
classifier match
PFD report
49match
Archie Hexall
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.
Matched on
classifier match
PFD report
49match
Margaret Wright
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Matched on
classifier match
PFD report
49match
Edna Cleaton
The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
Matched on
classifier match
PFD report
49match
Patricia Medland
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.
Matched on
classifier match
PFD report
49match
Lisa Day
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.
Matched on
classifier match
PFD report
49match
Monica Lewis-Hinds
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.
Matched on
classifier match
PFD report
49match
Debrata Sircar
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.
Matched on
classifier match
PFD report
49match
Barbara Sturgess
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.
Matched on
classifier match
PFD report
49match
Conall Gould
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.
Matched on
classifier match