Recurring concern

Failure to involve families and carers in discharge planning and decisions

First to latest report 30 Jan 2013 — 7 Nov 2025

Reports that mention this concern
35
Times this concern has been raised
40
Stated actions linked to this concern
36

What this concern includes

Includes failures in the discharge process to identify appropriate families or carers, seek and consider their views or information, involve them in complex discharge planning and decisions, and communicate material arrangements or risks to them where involvement is appropriate.

What is not included
  • Excludes failures in family or carer involvement outside discharge planning or discharge decisions.
  • Excludes communication solely between professionals, services or receiving organisations where family or carer involvement is not the unsafe condition.
  • Excludes failures limited to the clinical suitability of a discharge, housing, care-package provision or equipment unless the report also identifies exclusion of relevant families or carers from the discharge process.
  • Excludes mental-health care-planning involvement where discharge is not materially part of the asserted concern.

Reports and published responses 35 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North East Kent

    AI-generated summary

    Robert Arthur Brown · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Arthur Brown, who had a history of suicide attempts and suicidal ideation, was discharged from hospital after four days without his wife being contacted. On 9 September 2020, he was found fatally injured at cliffs close to his home address. The principal concerns were that “carer breakdown” might not be identified before discharge and that, without a process requiring contact with a carer where no CPA was in place, anticipated care might not be available.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a process to contact carers on discharge where no CPA is in place

    Wider context from the report

    “2. As there was no process in place to require contacting a carer on discharge where there is no CPA in place a patient could be discharged without notice to a carer and as such care that is anticipated to be in place on discharge may not be available. ”

    Source location

    Robert Arthur Brown · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. West Yorkshire Eastern

    AI-generated summary

    Neil Peter Bastock · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to heed family warnings about a patient’s fitness for discharge

    Wider context from the report

    “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”

    Source location

    Neil Peter Bastock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure Triangle of Care principles are enacted consistently for service users and family members.

    Verbatim wording from the response

    “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Kirsty Marie Doodes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to meaningfully involve families and carers in the discharge process

    Wider context from the report

    “iii) Lack of involvement of family/carer in discharge process The Trust’s own discharge policy states: 3. Principles The decision to discharge someone from hospital must be in keeping with the Care Programme Approach (CPA), (DH 1991, 2008) and governed by the following principles: The patient, carer and / or advocate, must be actively involved in all aspects of the discharge plan, where practicable. Arrangements for discharge should be negotiated with everyone likely to be concerned with the service user’s aftercare. ████████ was Kirsty’s carer. He had not been ‘actively involved in all aspects of the discharge plan.’ He had a phone call to come and collect her and on arriving at the hospital he found her bag to be packed. He did not feel as though he was given any choice. I acknowledged at inquest that there were extenuating circumstances in that Kirsty’s discharge coincided with the first national lockdown during the COVID pandemic. Nevertheless, I think it is appropriate to bring to your attention whether there is a need to remind clinicians to involve families and carers in a meaningful way during the discharge process. ”

    Source location

    Kirsty Marie Doodes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Trust’s mental health acute ward discharge policy and prioritise vital discharge steps and multidisciplinary roles and responsibilities.

    Verbatim wording from the response

    “With the above factors in mind, we have identified learning for us in that we need to support our clinicians to improve the discharge process and we therefore intend to review the Trust’s mental health acute ward discharge policy to support this.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work on reducing hospital length of stay towards the national average while following best evidence and allowing families time to understand discharge decisions.

    Verbatim wording from the response

    “Additionally, we are committed to working on the length of stay in our hospitals in an attempt to ensure that it is closer to the national average whilst continuing to work in line with best evidence such as the NICE Guidelines. This will often (and perhaps more frequently) mean that families and carers may find the rationale for discharge contrary to their wishes and/or counterintuitive. For this reason, time to enable families to work through, question and hopefully accept this will need to be prioritised as although Mr Doodes was involved in his wife’s discharge planning, we recognise that he did not feel as supportive of the plan as we would have liked.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review accepted clinical documentation standards to maximise clinicians’ time for compassionate, person-centred care and discussions with families and carers.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider including a concise template for documenting inpatient discharge decisions in the discharge policy review.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Finite services and limited clinical time prevent consistently prioritising comprehensive documentation alongside direct patient and family care.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

  4. West Sussex

    AI-generated summary

    James Kenneth Herbertson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform family supporters of discharge

    Wider context from the report

    “b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support. ”

    Source location

    James Kenneth Herbertson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.

    Verbatim wording from the response

    “Action Taken or Required Where the hospital/Trust agrees communication with families/carers is central to treatment and clinical decisions, it also has to maintain patient confidentiality where an”

    Source location

    2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
    Page 4 · response
    Published 24 March 2021

    Open published response

  5. Mid Kent and Medway

    AI-generated summary

    CHRISTOPHER SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform families of discharge home when care is required

    Wider context from the report

    “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care. ”

    Source location

    CHRISTOPHER SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Cumbria

    AI-generated summary

    Charlotte Grace · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlotte Grace was discharged from hospital on 20 September 2018 and was found hanging the following evening; the inquest recorded that she took her life by hanging on 21 September 2018. The principal concern was that the Home Treatment Team and her nominated next of kin were not invited to the discharge meeting, despite her being at chronic high risk of suicide and being referred for follow-up care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to routinely involve supportive families or friends in the discharge process

    Wider context from the report

    “(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted. 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting. I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process. ”

    Source location

    Charlotte Grace · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.

    Verbatim wording from the response

    “6. In order to monitor the discharge process the Trust use a safer discharge audit. This audit is used on each ward and monitors the following information:”

    Source location

    2019-0402-Response-by-Cumbria-NHS-Trust
    Page 2 · response
    Published 29 December 2019

    Open published response

  7. Manchester South

    AI-generated summary

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of discharge planning to share risk information with GPs and families

    Wider context from the report

    “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective. Key information was not shared with the GP or the family particularly when care moved back to the family; ”

    Source location

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. East London

    AI-generated summary

    Brenda Kathleen GOWAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to take family views into account in discharge planning

    Wider context from the report

    “(1) Brenda was discharged home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There is no evidence that the family’s views were taken into account by the discharging team. ”

    Source location

    Brenda Kathleen GOWAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to agree key care-plan aspects with community carers before discharge

    Wider context from the report

    “(6) There was no such care plan in place address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge. ”

    Source location

    Brenda Kathleen GOWAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reformat family care-planning documentation to record agreed expectations and actions, with multidisciplinary team involvement.

    Verbatim wording from the response

    “Following the concerns raised by the family in regards to feeling that they lacked choice and support during the discharge process, there has been a review of the communication and documentation following a Family Care Planning Meeting ensuring that there is signed understanding of the expectations and actions by all parties. This reformatted documentation will support accountability and be uploaded to the electronic notes system and a copy given to the patient and family. This will include all of the MDT (multidisciplinary team) looking after the said patient.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Upload care-planning documentation to electronic notes and provide copies to patients and families.

    Verbatim wording from the response

    “Following the concerns raised by the family in regards to feeling that they lacked choice and support during the discharge process, there has been a review of the communication and documentation following a Family Care Planning Meeting ensuring that there is signed understanding of the expectations and actions by all parties. This reformatted documentation will support accountability and be uploaded to the electronic notes system and a copy given to the patient and family. This will include all of the MDT (multidisciplinary team) looking after the said patient.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    Open published response

  9. Surrey

    AI-generated summary

    Emmett Alexander Gillah · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate communication with families about treatment decisions and discharge

    Wider context from the report

    “(3) More broadly to those issues raised at (1) & (2), communication arrangements in existence within KMPT between staff engaged in the care of a patient and patient families who may be directly affected by decisions relating to the patient’s treatment, were inadequate e.g. Mr Gillah’s family were not consulted in relation to the decision to discharge Mr Gillah or received any formal communication in relation to the circumstances of Mr Gillah’s discharge. ”

    Source location

    Emmett Alexander Gillah · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  10. West Yorkshire Eastern

    AI-generated summary

    Eileen Cooke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Eileen Cooke, an 80-year-old woman with dementia, frailty, contractures and a fractured left ankle, died in Pinderfields Hospital on 21 December 2017. Concerns included the lack of a best-interests multidisciplinary meeting, her discharge to a nursing home with unresolved medical and care needs, inadequate preparation for wound dressing and pain control, and the risk posed to other patients by precipitously arranged hospital discharges.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to involve and inform families in complex discharge decisions

    Wider context from the report

    “3. The family were not involved in her discharge from hospital at all. It was arranged in haste. Inadequate preparatory work had been done to establish how her wound dressing could be carried out and the pain control needed whilst this was done. No consideration was given to the skills required to achieve this, or the wisdom of involving a tissue viability nurse. 4. Evidence taken from healthcare professionals at the Inquest indicated that the 7.11.17 discharge was an error of judgement. It effectively passed an unresolved problem to a nursing home. 5. A ‘best interests’ meeting was required to assess her needs and formulate a management plan. This should have involved the orthopaedic surgeon, the vascular surgeon, nurses, a physio-therapist, a care of the elderly physician, a palliative care specialist, the general practitioner and the family. In the event no such meeting was arranged. It appeared difficult for senior clinicians to get hold of each other. Even if the issues proved unsolvable the family would have at least understood the position and could brace themselves for a period of palliative care, rather than being left in the dark. ”

    Source location

    Eileen Cooke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Coordinate frail older patients’ discharge plans with patients, families, representatives and relevant care providers, including capacity and safeguarding considerations.

    Verbatim wording from the response

    “Discharge plans for frail older patients are discussed with patients themselves and often their family or next of kin. In those who lack capacity to make decisions for themselves, discharge plans are discussed with relatives especially those who have Power of Attorney over health and well-being. The Trust has a safeguarding adult team to support clinical teams in their decisions and discussion if required.”

    Source location

    2018-0311-Response-Mid-Yorkshire-Hospitals
    Page 2 · response
    Published 23 February 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026