Recurring concern

Failure to involve families and carers in discharge planning and decisions

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First reported 30 Jan 2013•Latest report 7 Nov 2025

Definition

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.

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
35

Distinct published reports

Individual concerns
40

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
36

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust3
Department of Health and Social Care2
Kent and Medway Mental Health NHS Trust2
Princess Royal Hospital, Haywards Heath2
Sussex Partnership NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Aneurin Bevan University LHB1
Cheshire and Wirral Partnership NHS Foundation Trust1
Cornwall Council1
Cornwall Partnership NHS Foundation Trust1
County Durham and Darlington NHS Foundation Trust1
Cygnet Health Care Limited1
Department for Education1
Derby City Council1
Derbyshire Constabulary1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Plymouth, Torbay and South Devon

    AI-generated summary

    Martin Glyn Baker · 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

    Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

    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 psychiatric care

    Wider context from the report

    “(1) It was accepted in evidence that there had been a lack of communication with the family. They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest I expressed my view that where a patient has signed a consent form authorising discussion of relevant events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient’s subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker’s condition. ”

    Source location

    Martin Glyn Baker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Somerset

    AI-generated summary

    Edward Arthur Lundy · 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

    Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

    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 document discharge consultation and explicitly discuss risks with families

    Wider context from the report

    “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”

    Source location

    Edward Arthur Lundy · Prevention of Future Deaths report
    Page 1 · 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 provide independent consultation with families on discharge to family care

    Wider context from the report

    “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”

    Source location

    Edward Arthur Lundy · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    RYAN JAMES VOUT · 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

    Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.

    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 before discharge

    Wider context from the report

    “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge; ”

    Source location

    RYAN JAMES VOUT · 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

    Revise the Mental Health Act Code of Practice to set guiding principles for improving patient care.

    Verbatim wording from the response

    “The Mental Health Act 1983 Code of Practice, whilst being statutory guidance for providers of services under the Act, should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act. We revised the Code of Practice in 2015 and set out guiding principles to improve the care for patients. The principles include mental health providers involving patients’ carers and families in decisions about their care. The Code of Practice also makes it clear that we expect multi-disciplinary teams involved in care planning and discharge to include all relevant professionals and agencies which may be involved in a person’s care.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 2 · response
    Published 12 February 2018

    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

    Established multidisciplinary referral and assessment processes are considered sufficient to support coordinated discharge and community aftercare.

    Verbatim wording from the response

    “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;”

    Source location

    2017-0376-Response-by-Nottinghamshire-County-Council
    Page 1 · response
    Published 12 February 2018

    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

    Operational discharge and conveyance arrangements are matters for local health services, commissioners, providers, ambulance services and police.

    Verbatim wording from the response

    “The other two areas of concern fall to health services. The matters raised are operational and relate to the Nottinghamshire Healthcare NHS Foundation Trust and the ambulance service and I trust the responses you will receive from those organisations will be helpful. My response will focus on the national policy expectations in relation to the issues you have raised.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 1 · response
    Published 12 February 2018

    Open published response

  4. Inner North London

    AI-generated summary

    Doreen Elma STAPLETON · 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

    Doreen Stapleton died at Whittington Hospital on 15 September 2016 from a pulmonary thromboembolism, after previously being diagnosed with pulmonary emboli. Following discharge, district nurses were intended to administer daily tinzaparin injections, but the referral was not received because an obsolete email address was used. The principal concern was that Doreen and her sons were not given sufficiently explicit advice about the potentially fatal consequences of missed medication and were not given the district nursing team’s telephone number or told to call if nurses did not attend.

    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 provide explicit discharge advice about the fatal consequences of district nursing visits and medication administration not taking place

    Wider context from the report

    “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place. She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day. I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice. I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did. I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission. ”

    Source location

    Doreen Elma STAPLETON · 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

    Write to doctors, senior nurses and pharmacists highlighting learning points for embedding in clinical practice.

    Verbatim wording from the response

    “1) ████████ and I, as Director of Nursing and Patient Experience and Executive Medical Director respectively, will write to our doctors and senior nurses and pharmacists to highlight what we think are the key learning points that arise out of your concerns, so that they can consider how to embed these in their clinical practice from now on.”

    Source location

    Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
    Page 1 · response
    Published 5 March 2017

    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

    Share learning with inpatient pharmacists to support patients’ understanding of medication significance at discharge.

    Verbatim wording from the response

    “5) I have asked our Chief Pharmacist to share this learning with all pharmacists on our inpatient wards so that they can make an important contribution to ensuring that patients understand the significance of their medication on discharge.”

    Source location

    Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
    Page 2 · response
    Published 5 March 2017

    Open published response

  5. Gwent

    AI-generated summary

    Mrs Georgina Lewis · 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

    Mrs Georgina Lewis was discharged from a psychiatric unit on 23 September 2013, went missing from home on 27 September, and was found dead in woods near her home on 30 September 2013. Concerns included discharge without family consultation, no discharge plan or follow-up support, and delayed notification to her GP.

    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 notify or consult family members before discharge decisions

    Wider context from the report

    “(1) The decision to discharge was made without notification to or consultation with any family member. ”

    Source location

    Mrs Georgina Lewis · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Milton Keynes

    AI-generated summary

    James Francis Flynn · 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 Francis Flynn, who had chronic pancreatitis, was discharged home late on 8 December 2015 and was found unresponsive at home the following day; death was confirmed at 18:06. Concerns included discharge while he remained very unwell without a detailed care plan, with his immediate family unaware and no food or provisions available despite his type 2 diabetes, and that inadequate discharge planning and management could put patients’ lives at risk.

    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 immediate family of patient discharge

    Wider context from the report

    “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic. (2) Inadequate planning and management of patient discharge will put patients lives at risk. ”

    Source location

    James Francis Flynn · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Komang Jack SUSIANTA · 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

    Jack was a 17-year-old boy who developed a drug-related psychotic episode after taking cannabis and ecstasy, was detained by police and taken to hospital, and was discharged after assessment. His condition deteriorated after discharge; he later entered a river while being pursued by police and drowned. The principal concern was that the hospital did not communicate to his family the expected recovery, warning signs of recurrence, or when and how to seek urgent professional help.

    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 communicate clinical expectations to patients and families before discharge

    Wider context from the report

    “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

    Source location

    Komang Jack SUSIANTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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

    Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early discharge.

    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 for family members to provide views and information to early-discharge decision-makers

    Wider context from the report

    “(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for discharge. ”

    Source location

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  9. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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

    Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

    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 patients and families in discharge decisions

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Milton Keynes

    AI-generated summary

    John Andrews · 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

    John Andrews, who had a history of stroke and recurrent falls, was admitted after falls at home and later developed pneumonia and died on 1 June 2014. The principal concern was that he was discharged home without his family being advised, with no groceries or heating and without formal care arrangements in place; he fell while home alone before care was arranged.

    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 advise family members of discharge

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr Andrews was admitted to Milton Keynes Hospital on 31st March 2014 following a fall. (2) Following detailed discussion with ████████ Mr Andrews was discharged from hospital. (3) Mr Andrews was insistent that he wanted to be discharged. (4) ████████ agreed reluctantly, but decided that a discharge would be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital. (5) Upon discharge the plan agreed with ████████ was to implement a care package to assist Mr Andrews at home. (6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance. (7) Formal care arrangements were not arranged until 2-3 days later (Monday). It was too late, as Mr Andrews had fallen when home alone on the first day and was found on the floor by his son, who happened to phone his father, to be told he was at home. (8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home to meet their needs. ”

    Source location

    John Andrews · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026