Recurring concern

Failure to ensure discharge information is accessible and understood by patients and carers

First to latest report 20 Aug 2013 — 3 Jun 2026

Reports that mention this concern
17
Times this concern has been raised
19
Stated actions linked to this concern
16

What this concern includes

Includes failures within the patient- and carer-facing discharge communication process, including accessible discharge instructions or summaries, confirmation of understanding, alternative communication formats, and communication of follow-up arrangements.

What is not included
  • Excludes failures concerning the clinical content or quality of discharge summaries when the issue is not their accessibility to or understanding by patients or carers.
  • Excludes communication of discharge information solely between professionals, such as notifying GPs or transferring information to another service.
  • Excludes general communication, literacy, training or documentation deficiencies not specifically tied to discharge information for patients or carers.
  • Excludes failures to coordinate whether a receiving service or care home can accept a patient, where the concern is discharge logistics rather than patient- or carer-facing discharge information.

Reports and published responses 17 reports

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

  1. Nottingham and Nottinghamshire

    AI-generated summary

    David MARRIOTT · 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

    David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries to patients.

    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 supply ED discharge summaries to patients

    Wider context from the report

    “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such. I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning. I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient. The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified? ”

    Source location

    David MARRIOTT · Prevention of Future Deaths report
    Page 5 · 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 and publish a patient information leaflet explaining pneumonia follow-up requirements and their importance.

    Verbatim wording from the response

    “Discharge Summary The ED respiratory speciality interface collaborative team are designing a patient information leaflet to be given to those patients being discharged with pneumonia, based on BTS guidance. This will include patient information about the need to see the GP at 6 weeks for follow-up and why this matters. This leaflet will be completed in Draft Format by end of August 2026 and is expected for publication by October 2026 and can be shared if required.”

    Source location

    Response from Nottingham University Hospitals NHS Trust
    Page 3 · response
    Published 13 August 2026

    Open published response

  2. Warwickshire

    AI-generated summary

    Ethan Michael Hanson · 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

    Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.

    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 structured local support for interpreting neurodivergent parental communication

    Wider context from the report

    “Local processes provide no structured support for neurodivergent children or parents Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted. ”

    Source location

    Ethan Michael Hanson · Prevention of Future Deaths report
    Page 4 · 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

    Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.

    Verbatim wording from the response

    “• The learning from this case is being built into a simulation programme. The upcoming CAU simulation sessions will involve a wider multi-disciplinary group and will include scenarios around abdominal pain, including neurodivergent children, to support better recognition, communication, and escalation. These sessions are held monthly.”

    Source location

    Response from George Eliot Hospital NHS Trust
    Page 3 · response
    Published 25 June 2026

    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 and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.

    Verbatim wording from the response

    “• The Trust’s Communications Team is developing a formal communications plan, in partnership with the Paediatric Neurodiversity & Learning Disability Lead, to increase awareness and utilisation of Hospital Passports and “All About Me” tools. This will include a public-facing campaign, commencing in July 2026 and continuing thereafter.”

    Source location

    Response from George Eliot Hospital NHS Trust
    Page 5 · response
    Published 25 June 2026

    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

    Establish neurodivergent champion roles across GEH and SWFT with a dedicated training programme.

    Verbatim wording from the response

    “• A neurodivergent champion role is being established across GEH and SWFT, supported by a dedicated training programme. These roles will act as advocates for neurodivergent patients and their families, with implementation scheduled from July 2026.”

    Source location

    Response from George Eliot Hospital NHS Trust
    Page 5 · response
    Published 25 June 2026

    Open published response

  3. East London

    AI-generated summary

    Andrew Ewin-Ripp · 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 Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.

    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 guidance on contacting the secondary care team after recurrent seizures

    Wider context from the report

    “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern: (1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures. (2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this. (3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge. (4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication. ”

    Source location

    Andrew Ewin-Ripp · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. North East Kent

    AI-generated summary

    KEITH RUPERT DIMOND · 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

    Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.

    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 written and family-shared bleeding-risk advice for direct oral anticoagulant medication

    Wider context from the report

    “(2) The patient was discharged on 19 October 2022 with a new diagnosis of Atrial Fibrillation and prescription of Direct Oral Anticoagulant Apixaban was prescribed. The patient was not given any written advice on the risks as to bleeding on this medication and the risks were not shared with family on discharge. This led to advice being sought from 111 and a long delay before 999 was called when the patient deteriorated on 22 October 2022. ”

    Source location

    KEITH RUPERT DIMOND · 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

    Create and implement a generic anticoagulant discharge leaflet covering bleeding risks, warning signs and when to seek medical attention.

    Verbatim wording from the response

    “I can confirm that the Trust is in the process of creating and implementing a generic anticoagulant patient leaflet, which will be provided to patients upon discharge from hospital. The leaflet will cover information around risks of bleeding, signs and symptoms to look for in terms of bleeding and when to seek medical attention. The leaflet is due to be finalised by the end of March 2023.”

    Source location

    Response from East Kent Hospitals University
    Page 2 · response
    Published 28 October 2022

    Open published response

  5. West Sussex

    AI-generated summary

    James Kenneth Herbertson · 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 Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.

    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 supporters of discharge

    Wider context from the report

    “b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support. ”

    Source location

    James Kenneth Herbertson · Prevention of Future Deaths report
    Page 3 · 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 notify vulnerable service users’ parents of discharge

    Wider context from the report

    “b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support. ”

    Source location

    James Kenneth Herbertson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.

    Verbatim wording from the response

    “Action Taken or Required Where the hospital/Trust agrees communication with families/carers is central to treatment and clinical decisions, it also has to maintain patient confidentiality where an”

    Source location

    2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
    Page 4 · response
    Published 24 March 2021

    Open published response

  6. Norfolk

    AI-generated summary

    Pauline 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

    Pauline Russell, a poorly controlled diabetic, was discharged from hospital after her insulin dose was increased, but she and her husband could not read the written discharge instructions. She subsequently received a higher incorrect insulin dose, became unresponsive in a hypoglycaemic coma, and died from aspiration pneumonia. The principal concern was that the hospital did not check patients’ literacy or provide discharge instructions in an accessible alternative format.

    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 discharge instructions are accessible and understood by patients

    Wider context from the report

    “No one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that ████████ could read and understand the discharge summary. The inquest was 8 months after Mrs Russell’s death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again. ”

    Source location

    Pauline Russell · 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

    Review admission and discharge documentation across the Trust to identify required changes.

    Verbatim wording from the response

    “Following your inquest, the hospital’s Director of Nursing instigated a review of the admission and discharge documentation used across the Trust to identify any required changes.”

    Source location

    2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
    Page 1 · response
    Published 16 October 2020

    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

    Amend admission and discharge documentation to include literacy checks, support requirements and signposting to the admissions booklet.

    Verbatim wording from the response

    “As a result of this review, the admission and discharge documentation has been amended to include additional checks relating to literacy support. The Multi-Disciplinary Care Record now requires staff to check whether the patient is able to read English and if any additional support is required. The ‘Discharge Checklist’ also highlights language and literacy skills to the completing staff and signposts them to the new admissions booklet. Please see enclosed copy of the amended documentation. The updated documentation has been”

    Source location

    2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
    Page 1 · response
    Published 16 October 2020

    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

    Launch and cascade the amended documentation through ward managers at the Clinical Leaders Event.

    Verbatim wording from the response

    “As a result of this review, the admission and discharge documentation has been amended to include additional checks relating to literacy support. The Multi-Disciplinary Care Record now requires staff to check whether the patient is able to read English and if any additional support is required. The ‘Discharge Checklist’ also highlights language and literacy skills to the completing staff and signposts them to the new admissions booklet. Please see enclosed copy of the amended documentation. The updated documentation has been”

    Source location

    2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
    Page 1 · response
    Published 16 October 2020

    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

    Audit compliance with the amended admission and discharge documentation monthly, beginning with results available at the end of October.

    Verbatim wording from the response

    “shared with ward managers to cascade accordingly and the documentation will be formally launched at the Clinical Leaders Event on 7 October 2020. To ensure compliance, the Trust will carry out a monthly audit of this documentation with the first results available at the end of October.”

    Source location

    2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
    Page 2 · response
    Published 16 October 2020

    Open published response

  7. Worcestershire

    AI-generated summary

    Kevin John McDonald · 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

    Kevin John McDonald was admitted to hospital after a spinal injury, was assessed and discharged with analgesia, apparently without follow-up. He later died by suicide, leaving a note indicating that he could no longer tolerate the pain. Concerns included unclear discharge advice and follow-up arrangements, with the family stating that he was left unsure what to do about his increasing pain and that no relevant hospital documentation had been found.

    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 clear discharge follow-up advice and guidance

    Wider context from the report

    “(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this. ”

    Source location

    Kevin John McDonald · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. East London

    AI-generated summary

    Brenda Kathleen GOWAN · 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

    Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.

    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 assess and communicate night-time falls risk at discharge

    Wider context from the report

    “(2) Brenda was at risk of falling at night. There is no evidence that the risk was fully assessed on discharge from hospital and no evidence of the family being provided with advice on how to manage the risk. ”

    Source location

    Brenda Kathleen GOWAN · 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

    Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.

    Verbatim wording from the response

    “The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available. Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    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

    Monitor discharge-checklist completion through Ward Manager oversight.

    Verbatim wording from the response

    “The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available. Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    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

    Reassess changed care needs through a senior professional and identify risks requiring further intervention.

    Verbatim wording from the response

    “The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available. Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    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

    Include reviewed carer guidelines in discharge information and provide accessible onward-referral and joint-planning contact details.

    Verbatim wording from the response

    “The current provision of carer guidelines has been reviewed and will be included in the discharge information provided to the patient and family on leaving hospital as part of the discharge checklist. This will ensure that contact details in regards to onward referral and joint health and social care planning are accessible.”

    Source location

    2019-0064_Response-by-Barts-Health-NHS-Trust
    Page 3 · response
    Published 2 June 2019

    Open published response

  9. West London

    AI-generated summary

    Dennis Peter Alfred Warner · 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

    Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.

    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 discharge information in a form the patient could comprehend and retain

    Wider context from the report

    “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate. ”

    Source location

    Dennis Peter Alfred Warner · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Dorothy Joan Strickley · 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

    Dorothy Joan Strickley underwent emergency surgery for appendicitis on 10 June 2018 and was discharged without the anti-embolic stockings prescribed to her or information about continuing to wear them and seeking urgent medical attention. She became short of breath at home and died 19 days after surgery from a massive pulmonary embolism; concerns included failures to provide the stockings, communicate their use, and ensure discharge documentation and local policy reflected relevant guidance.

    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 AES discharge instructions and correct use

    Wider context from the report

    “A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”

    Source location

    Dorothy Joan Strickley · Prevention of Future Deaths report
    Page 1 · 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