Recurring concern

Failure to ensure safe post-discharge arrangements for vulnerable patients and residents

Pin Get email alerts Request correction

First reported 26 Nov 2013•Latest report 14 Apr 2026

Definition

What this concern includes

Includes failures in discharge or return arrangements for vulnerable, challenging or clinically dependent patients and residents where responsible services do not reliably establish, coordinate or communicate the support and protective arrangements needed after discharge, including required advice from social services or comparable care functions.

Not included

  • Excludes routine discharge delays or unsuitable discharge timing where post-discharge safety arrangements are not the deficient condition.
  • Excludes failures confined to a named mental-health, hospital-to-care-home, prison-release or other specialised discharge pathway when that pathway provides the more specific supported boundary.
  • Excludes failures in care or treatment after safe discharge arrangements have been established.
  • Excludes generic communication, staffing or documentation deficiencies unless they directly leave a vulnerable person without safe post-discharge arrangements.
Reports
34

Distinct published reports

Individual concerns
44

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
53

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.

Department of Health and Social Care4
Kent County Council2
North Cumbria Integrated Care NHS Foundation Trust2
Worcestershire County Council2
Aneurin Bevan University LHB1
Barts Health NHS Trust1
Care Quality Commission1
Central London Community Healthcare NHS Trust1
Chesterfield Royal Hospital1
City of Doncaster Council1
Cornwall Council1
County Durham and Darlington NHS Foundation Trust1
Cumbria County Council1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Grasmere Surgery1

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. 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

    Lack of a pressure-relieving mattress at discharge home

    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 respondent action was interpreted

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

    PFD Monitor interpretation

    Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.

    Verbatim wording from the response

    “All patients returning home with care package will have their equipment needs assessed and documented in hospital.”

    Source location

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

    Open published response
  2. Gwent

    AI-generated summary

    DESGRAE REGINA TUCKER · 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

    Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on 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 consider discharge home with anti-embolic stockings

    Wider context from the report

    “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed. (2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings. (3) No anti-coagulant medication prescribed to the patient upon discharge. ”

    Source location

    DESGRAE REGINA TUCKER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. South Yorkshire (Eastern)

    AI-generated summary

    ROSEMARY BRONWYN FERGUSON · 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

    ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of 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 Social Services of discharge contrary to their recommendations

    Wider context from the report

    “(1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to them. ”

    Source location

    ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. 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 proper accommodation is provided 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
Back to top

Data last updated 7 September 2026