Concerns raised 1
Failure to arrange cardiology follow-up after discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England the Shrewsbury and Telford Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
the Shrewsbury and Telford Hospital NHS Trust
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
View source
the Shrewsbury and Telford Hospital NHS Trust
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
View source
the Shrewsbury and Telford Hospital NHS Trust
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
View source
the Shrewsbury and Telford Hospital NHS Trust
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
View source See 1 more action
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AI-generated summary
Lynn SILCOCK · 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
Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange cardiology follow-up after discharge
Wider context from the report “(2) Discharged without a cardiology clinic appointment or plan to be later referred .
” Source location Lynn SILCOCK · Prevention of Future Deaths report
Open source report
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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 a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Verbatim wording from the response “The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter.” Source location Response from Shrewsbury and Telford Hospital
Open published response
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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 Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Verbatim wording from the response “In the short to medium term the Trust’s Medical Director and Deputy Medical Director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals. This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned.” Source location Response from Shrewsbury and Telford Hospital
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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 Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Verbatim wording from the response “There will be a single referral email for each specialty for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next 3 months with SOPs developed and appropriate communications cascaded.” Source location Response from Shrewsbury and Telford Hospital
Open published response
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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 Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Verbatim wording from the response “A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the overall programme of work to mature the Trusts digital systems).” Source location Response from Shrewsbury and Telford Hospital
Open published response
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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 Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Verbatim wording from the response “The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised with cardiology advising these should be completed first then cardiology would continue the process to investigate the aortic stenosis. On review it is clear there was no expectation that the gastroenterology team would be responsible for following up the referral to cardiology once Ms Silcock’s endoscopy investigations were completed.” Source location Response from Shrewsbury and Telford Hospital
Open published response
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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 concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
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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 Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
Open published response
Concerns raised 1
Delays in outpatient follow-up for ear infections View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Royal Devon University Healthcare NHS Foundation Trust Somerset NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Somerset NHS Foundation Trust
Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.
View source
Royal Devon University Healthcare NHS Foundation Trust
Strengthen ENT outpatient follow-up monitoring through booking validation, waiting-list dashboards, overdue-date tracking, additional booking-office staffing and routine capacity reviews.
View source
Royal Devon University Healthcare NHS Foundation Trust
Use the EPR fast-pass system to offer suitable vacant outpatient slots to patients through the MyCare application.
View source
Royal Devon University Healthcare NHS Foundation Trust
Introduce virtual ticket scheduling through MyCare, with appointment notifications, patient self-booking and letters for patients without the application.
View source See 1 more action
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AI-generated summary
Andrew James Tizard-Varcoe · 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
Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in outpatient follow-up for ear infections
Wider context from the report “(2) In addition, the evidence revealed that there were three occasions when Mr Tizard-Varcoe was not followed up as an outpatient in a timely manner (August 2021, November 2021 and February 2022). On one occasion Mr Tizard-Varcoe possibly ran out of antibiotic medication and on another Mr Tizard-Varcoe was discharged without antibiotic medication. The lack of timely follow up appointments resulted in reduced monitoring and assessment and a poor understanding of the effectiveness of treatment and the progression of his ear infection.
” Source location Andrew James Tizard-Varcoe · Prevention of Future Deaths report
Open source report
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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 Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.
Verbatim wording from the response “Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.” Source location Response from NHS Somerset
Open published response
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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 Strengthen ENT outpatient follow-up monitoring through booking validation, waiting-list dashboards, overdue-date tracking, additional booking-office staffing and routine capacity reviews.
Verbatim wording from the response “At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Use the EPR fast-pass system to offer suitable vacant outpatient slots to patients through the MyCare application.
Verbatim wording from the response “Another one of the changes that has been implemented is that the use of the EPR system has been further developed to include a “fast pass” and “ticket scheduling system” that sends out any vacant slots to the patients suitable for booking up to 6 times daily via the MyCare (EPR app) until the slots are filled. Patients can bring pre-booked appointments forward to a closer date.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Introduce virtual ticket scheduling through MyCare, with appointment notifications, patient self-booking and letters for patients without the application.
Verbatim wording from the response “Ticket scheduling is another change due to be brought in which will be a virtual booking system on our MyCare app. This feature will send out notifications to the patients inviting them to book an appointment, the app will present all available slots to the patient for booking. All bookings are completed and confirmed via the app. Any patients without the app will be sent standard letters inviting them to clinic. This will avoid patients having to call into the office for an appointment which will be much faster.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Existing ENT waiting-list monitoring and patient-service correspondence are considered sufficient for effective outpatient follow-up.
Verbatim wording from the response “Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.” Source location Response from NHS Somerset
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 Enhanced booking validation, waiting-list monitoring, staffing and electronic scheduling are considered sufficient to monitor ENT outpatient follow-ups efficiently.
Verbatim wording from the response “At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
1 Mar 2023 Annabel Jean Findlay · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Failure to arrange follow-up appointments before discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Priory Group
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
View source
Priory Group
Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
View source
Priory Group
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
View source
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AI-generated summary
Annabel Jean Findlay · 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
Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause of death.
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× 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 arrange follow-up appointments before discharge
Wider context from the report “Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021.
A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release.
B. No follow up appointment was booked prior to Ms. Findlay’s discharge .
C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge).
” Source location Annabel Jean Findlay · Prevention of Future Deaths report
Open source report
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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 Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
Open published response
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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 a further reminder requiring outpatient follow-up appointments to be booked before discharge.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
Open published response
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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 Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
Open published response
1 Oct 2021 Stephen Thomas BARTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1
Lack of tracking systems for non-cancer outpatient appointments View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Stephen Thomas BARTON · 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
Stephen Thomas BARTON, a serving prisoner, was found dead in his cell at HMP Dovegate on 27 July 2019; the circumstances state that death resulted from an ear condition. He missed numerous outpatient appointments, and concerns were raised about the lack of systems to track such appointments and about insufficient access to secondary healthcare, alongside a conclusion of natural causes following a lack of proper primary healthcare intervention.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of tracking systems for non-cancer outpatient appointments
Wider context from the report “Stephen missed numerous out-patient appointments. I heard expert evidence from a hospital consultant indicating that in the great majority of cases there is no way of tracking out-patient appointments in the NHS . This is however done in cancer cases . The consultant felt it should not be too difficult to develop a system of tracking out-patient appointments in non-cancerous cases. If realistically this could be introduced it might well save a lot of administrative time and indeed prevent unnecessary deaths.
” Source location Stephen Thomas BARTON · Prevention of Future Deaths report
Open source report
12 Dec 2017 Francis Robert Beech · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to arrange an outpatient appointment within 3 weeks of discharge View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Francis Robert Beech · 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
Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.
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 arrange an outpatient appointment within 3 weeks of discharge
Wider context from the report “4. Failing to arrange an outpatient appointment within 3 weeks of discharge .
” Source location Francis Robert Beech · Prevention of Future Deaths report
Open source report
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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 and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.
Verbatim wording from the response “Following the findings from this report, guidelines will be formulated for clinicians to follow for these patients. These will include recommended timescales for follow-up and x-ray reviews to be used in conjunction with clinical judgement. The new guidelines will be called ‘Conservative Management of Unstable Fractures’ and will be implemented by the Trust by 31 March 2018. Once the guideline has been implemented, the Directorate will audit compliance. If you would like to see the guidelines, please let me know.” Source location 2017-0367-Responses
Open published response
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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 Create three daily hot-clinic slots to provide capacity for expedited post-discharge Trauma and Orthopaedic follow-up.
Verbatim wording from the response “The Trust has taken steps to reduce the time that a patient will now experience when awaiting an outpatient appointment for a consultant in Trauma & Orthopaedics. To support patients being seen in outpatient appointments expeditiously the Trust has created 3 daily “hot clinic” slots for post discharge follow-up. This will ensure that there is capacity to facilitate these reviews.” Source location 2017-0367-Responses
Open published response
17 Jul 2017 Matthew Robert Edwards · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure follow-up appointments are booked before discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Matthew Robert Edwards · 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
Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.
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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 follow-up appointments are booked before discharge
Wider context from the report “2. The follow up appointment was not made for Mr Edwards on his discharge. When the discharge summary was dispatched subsequently this was not picked up and there was no system in place to ensure that follow up appointments had been booked prior to discharge.
” Source location Matthew Robert Edwards · Prevention of Future Deaths report
Open source report
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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 Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
Verbatim wording from the response “I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.” Source location Matthew-Edwards-Response
Open published response
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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 Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Verbatim wording from the response “This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.” Source location Matthew-Edwards-Response
Open published response
27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to effectively follow up patients who miss pre-booked clinical appointments View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Matthew RUSSELL · 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
Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to effectively follow up patients who miss pre-booked clinical appointments
Wider context from the report “c. An effective procedure for following up patients who fail to attend pre-booked appointments with clinicians .
” Source location Matthew RUSSELL · Prevention of Future Deaths report
Open source report
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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 Operate and share the In-Reach DNA procedure, including same-day follow-up, risk review and rebooking after missed appointments.
Verbatim wording from the response “The CNWL In-Reach Team has a DNA (Did Not Attend) Standard Operating Procedure in place which has been shared and discussed with all staff members.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
9 Oct 2015 Suzanne Samantha Greenwood · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to discharge patients after repeated missed appointments within defined timescales View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Suzanne Samantha Greenwood · 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
Suzanne Samantha Greenwood died at Haslam Park, Bolton, on 23 December 2014 after being found collapsed and unresponsive with a ligature around her neck; she had also taken Zopiclone and alcohol. The principal concerns were the absence of contact after she failed to attend appointments, her not being discharged or reported to her General Practitioner, and the lack of systems and timescales for managing missed appointments and notifying other healthcare professionals.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to discharge patients after repeated missed appointments within defined timescales
Wider context from the report “1. During the Inquest evidence was heard that
i. Mrs Greenwood had not been seen by ████████ at the Priory Hospital, Altrincham after her last review on the 21st November 2013 prior to her death on the 23rd December 2014. She had failed to attend appointments in January 2014 but there had been no contact with her, either by telephone or letter, following her failure to attend the appointment on the 16th January 2014.
ii. Mrs Greenwood had not been discharged by ████████ following her failure to attend her appointment on the 16th January 2014 and before her death on the 23rd December 2014 but there had been no contact with her for a period exceeding 11 months.
iii. ████████ had not made any contact with the General Practitioner to confirm Mrs Greenwood’s failure to attend her appointments in January 2014 and that she had not been seen after the 21st November 2013, which is a particular concern when an Advanced Nurse Practitioner reduced the medication initially prescribed by ████████ which she had the authority to reduce, in circumstances where ████████ had not seen Mrs Greenwood since the 21st November 2013.
iv. There are no systems, either in ████████ private practice or in the Priory Hospital, Altrincham to contact patients following a failure to attend appointments and to consider the discharge of patients when a patient repeatedly fails to attend appointments over a period of time . There are no timescales with regard to the discharge of patients and no system to contact General Practitioners or other health professionals in relation to the failure to attend appointments, particularly in circumstances where other health professionals are likely to continue to treat patients after the missed appointments, including changes in medication.
The importance of discharge within a reasonable period after a failure to attend appointments is important to enable other health professionals involved in continuing care to be aware of the non-attendance at appointments and the discharge. The fact that there has been no reported failure to attend appointments and no reported discharge would be misleading to other health professionals involved in continuing care, particularly when a patient has not been seen for a period in excess of 12 months and that information would not be available to other health professionals in the absence of information from the Hospital.
There is a need for health professionals involved in the continuing care of a patient to be kept informed as to the treatment or non-treatment of the patient at a hospital when considering further treatment in the community.
2. I request you to consider the above concerns and for both ████████ and The Priory Hospital, Altrincham to carry out a review with regard to the following.
i. The systems procedures, policies and protocols in relation to contact with patients who fail to attend appointments.
ii. The systems, procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that the patient will be discharged unless there is either contact or an appointment within a defined period.
iii. The systems, procedures, policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments with notification to General Practitioners or other health professionals of the patient’s failure to attend appointments and their discharge from hospital.
The review should consider timescales in relation to discharge when a patient has failed to attend appointments for a specific period of time.
iv. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
” Source location Suzanne Samantha Greenwood · Prevention of Future Deaths report
Open source report
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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 Require independent doctors to send discharge letters to GPs and relevant professionals after final non-attendance contact, copying patients and including medication, aftercare and crisis actions.
Verbatim wording from the response “In response to 2 and 3 please note that we have given full consideration to these matters and have now made the following requirements explicit in Policy H105: Practising Privileges for Independent Doctors:” Source location 2015-0370-Response-by-The-Priory_Redacted
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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 Notify Hospital Medical Directors of the revised requirements and require routine discussion of patient discharge during independent doctors’ supervision and appraisal.
Verbatim wording from the response “2. Our group Medical Director ████████ has notified Hospital Medical Directors of this requirement and has asked that the discharge of patients is routinely discussed during supervision and appraisal with Independent Doctors.” Source location 2015-0370-Response-by-The-Priory_Redacted
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11 Oct 2014 Mark Hancock · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to schedule outpatient appointments compatibly with patients' existing therapy commitments View source
This report raised 6 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.
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AI-generated summary
Mark Hancock · 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
Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to schedule outpatient appointments compatibly with patients' existing therapy commitments
Wider context from the report “- The consultant's out-patient appointment with the deceased had been booked to take place in the lunchtime when we was already in a full day therapy session .
” Source location Mark Hancock · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to arrange the patient's next outpatient appointment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals of Leicester NHS Trust
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AI-generated summary
Karen Lesley SUTTON · 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
Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange the patient's next outpatient appointment
Wider context from the report “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge.
(2) Mrs Sutton was discharged home without prophylactic antibiotic medication
(3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012 .
(4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide.
” Source location Karen Lesley SUTTON · Prevention of Future Deaths report
Open source report
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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 Patients may appropriately arrange their own outpatient appointments where clinical circumstances permit, alongside existing discharge and information-sharing arrangements.
Verbatim wording from the response “As to your third concern the circumstances surrounding the outpatient appointment with ████████ are unusual. I am informed that the on the 25th May 2012 an outpatient appointment with ████████ was booked for 4th October 2012 in accordance with normal procedures. As you are aware Mrs Sutton was subsequently admitted under the care of the respiratory team. It would seem that whilst there was a plan made on the 2nd October 2012 to cancel this appointment, as Mrs Sutton was then an inpatient, our Patient Administration system (HISS) indicates that this cancellation had not been put into effect by the 3rd October when Mrs Sutton was discharged. A plan was therefore made, prior to discharge, that Mrs Sutton should attend her pre-arranged appointment on 4th October 2012 with ████████.” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.