Recurring concern

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

First to latest report 26 Nov 2013 — 14 Apr 2026

Reports that mention this concern: 34
Times this concern has been raised: 44
Stated actions linked to this concern: 53

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

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

Reports and published responses 34 reports

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

30 Jan2014
Manchester South
Concerns raised1
1. Lack of a pressure-relieving mattress at discharge home
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions 1
1. Tameside and Glossop Integrated Care NHS Foundation Trust
  Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
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
23 Jan2014
Gwent
Concerns raised1
1. Failure to consider discharge home with anti-embolic stockings
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
12 Dec2013
South Yorkshire (Eastern)
Concerns raised1
1. Failure to notify Social Services of discharge contrary to their recommendations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
26 Nov2013
Avon
Concerns raised1
1. Failure to ensure proper accommodation is provided before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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