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. Brighton and Hove

    AI-generated summary

    Graham Harold WATTS · 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

    Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.

    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 discharge information to receiving care providers and family

    Wider context from the report

    “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

    Source location

    Graham Harold WATTS · 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

    Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.

    Verbatim wording from the response

    “The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 3 April 2014

    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

    Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.

    Verbatim wording from the response

    “The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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

    Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.

    Verbatim wording from the response

    “Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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

    Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.

    Verbatim wording from the response

    “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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

    The discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.

    Verbatim wording from the response

    “The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 3 April 2014

    Open published response

  2. Manchester South

    AI-generated summary

    Leslie Alfred Pates · 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

    Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.

    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 consider the family’s views before discharge planning and implementation

    Wider context from the report

    “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”

    Source location

    Leslie Alfred Pates · 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 hold the required pre-discharge meeting with the family

    Wider context from the report

    “5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place. ”

    Source location

    Leslie Alfred Pates · 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

    Develop a discharge checklist confirming MDT engagement with patients and families before discharge.

    Verbatim wording from the response

    “To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are being taken.”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 1 · response
    Published 30 January 2014

    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

    Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.

    Verbatim wording from the response

    “The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers.”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 2 · response
    Published 30 January 2014

    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

    Provide patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.

    Verbatim wording from the response

    “To ensure the patients and families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken:”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 2 · response
    Published 30 January 2014

    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

    Formulate complex care plans for all parties to agree before patients return home.

    Verbatim wording from the response

    “A complex care plan has been formulated for all parties to agree the patient is supported and fully ready for home.”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 2 · response
    Published 30 January 2014

    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

    Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.

    Verbatim wording from the response

    “All plans of care for patients must be shared with the patient and, with patient’s consent, their next of kin and agreed before discharge.”

    Source location

    2014-0043-Response-by-Tamside-Hospital-NHS
    Page 2 · response
    Published 30 January 2014

    Open published response

  3. Avon

    AI-generated summary

    Alan Stanfield · 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

    Alan Stanfield Browning was discharged from Somewhere House on 10 August 2012 after treatment for alcohol and drug abuse, and CCTV showed him jumping from Clifton Suspension Bridge on 16 August 2012. Concerns included discharge without family being informed about accommodation arrangements, discharge on a Friday leaving little time to secure accommodation, and uncertainty about routine family involvement before 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

    Failure to ensure family involvement in accommodation arrangements before discharge

    Wider context from the report

    “1. Mr. Browning was discharged from Somewhere House without his family being informed of arrangements for his accommodation. 2. He was also discharged on a Friday, as a result of which there was little time to ensure accommodation was provided, and no proper accommodation was found for him. 3. The evidence was unclear as to whether Somewhere House routinely ensured family involvement before discharge, even where a client consented to this. 4. The evidence established the importance of discharge and accommodation arrangements in vulnerable clients such as Mr. Browning ”

    Source location

    Alan Stanfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. County Durham and Darlington

    AI-generated summary

    Linda Hudson · 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

    Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after 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

    Failure to notify family members of discharge where family support is relevant to safety

    Wider context from the report

    “(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided. ”

    Source location

    Linda Hudson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Gareth Mark Slater · 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

    Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

    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 family in discharge planning

    Wider context from the report

    “4. There was no attempt to involve Gareth’s family in the discharge of Gareth. ”

    Source location

    Gareth Mark Slater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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