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recurance

Limited family involvement in care planning and risk assessment

Identical hazardConfidence 0.90 · high2 reports · 2023–2024 One-page brief (print or PDF)

Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 1 Sept 2023 and 4 Mar 2024.

They came from 1 coroner. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 6 specific actions.

2
reports
1
coroner
2023–2024
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Gerard Murray↗

    1 Sept 2023 · Elizabeth Didcock · Nottinghamshire

    “There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
    Original on judiciary.uk ↗

    Nottinghamshire Healthcare NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗

    “To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”
    “an electronic device is being procured which will allow multiple alarms to be set for each person's leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot.”

    4 more stated actions in the Promises tab.

  2. 6 months later

    Raised again · 1st time

    Kenneth Baylis↗

    4 Mar 2024 · Elizabeth Didcock · Nottinghamshire

    Identical hazardConfidence 0.90 · high
    “Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Familycareplan

    Nottinghamshire Healthcare NHS Foundation Trust responded.Response (PDF) ↗

  3. All reports to Nottinghamshire Healthcare NHS Foundation Trust

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error