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. West Yorkshire (Western)

    AI-generated summary

    Stanford Shirley Bell · 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

    Stanford Shirley Bell, who had dementia, fell at Riverview Nursing Home on 22 February 2018 and later died on 2 March 2018 after suffering seizures and an acute on chronic subdural haematoma. Concerns included the absence of hospital discharge papers and written neurological-observation recommendations, and delayed referral from the care home after seizures following head trauma.

    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

    Absence of discharge papers for patients neurologically assessed with head injuries

    Wider context from the report

    “For Airedale Hospital to review procedures at hospital discharge with respect to patients neurologically assessed with head injuries given the absence of discharge papers ”

    Source location

    Stanford Shirley Bell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. London (East)

    AI-generated summary

    William George BARTRAM · 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

    William Bartram was born with a chordee and hydrocele and was reported to have an inadequate urine stream from shortly after birth. Raised creatinine results and concerns about his urine output were not acted upon, and he died from septic shock on 12 March 2017 after deteriorating in hospital. The principal concerns were unclear processes for repeat blood samples, failure to highlight or act on abnormal results, and inadequate advice to his parents about what constituted a healthy urine stream.

    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 clear discharge advice to parents about a healthy urine stream in babies

    Wider context from the report

    “(3) Mr and ████████ did not receive clear advice as to what to look out for, in terms of a healthy urine stream. Advice to parents on the discharge of babies from hospital, would be helpful. Mr and ████████ accepted reassurance from staff, as they were unclear as to what was “normal”. ”

    Source location

    William George BARTRAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Conall Patrick Gould · 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

    Conall Patrick Gould died at Queen Elizabeth Hospital in Birmingham on 13 February 2017 after behaving erratically and collapsing; the medical cause of death was recorded as ecstasy use. The report raised concerns that arrangements for his community mental health follow-up appointment after discharge were not communicated to him or his parents, and that the absence of a clear protocol or written confirmation created a risk that follow-up opportunities could be missed.

    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 that service users and carers receive follow-up appointment details on discharge

    Wider context from the report

    “1. At the time of discharge from Holywell Hospital on the 30th January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2nd February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence of ████████ Consultant Psychiatrist, who saw Conall and his father on the 30th January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust ████████ had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30th January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4. The evidence of ████████ who conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost. ”

    Source location

    Conall Patrick Gould · Prevention of Future Deaths report
    Page 1 · 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

    Implement enhanced discharge documentation requiring written follow-up details, contact numbers, and agreed information for patients and carers.

    Verbatim wording from the response

    “The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 day follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge. This protocol also directs that a relative/concerned other, identified by the patient, will also be provided with this written information when consent to do so has been given by the patient.”

    Source location

    Conall-Patrick-Response
    Page 1 · response
    Published 28 September 2017

    Open published response

  4. Black Country

    AI-generated summary

    Melvin James and Anne-Marie James · 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

    Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following 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 communicate relapse warning signs to family

    Wider context from the report

    “2. He also accepted that there was a missed opportunity in communication and information sharing and it was regrettable they didn’t speak to the family and explain what symptoms to look out for in case of relapse. ”

    Source location

    Melvin James and Anne-Marie James · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Doreen Elma STAPLETON · 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

    Doreen Stapleton died at Whittington Hospital on 15 September 2016 from a pulmonary thromboembolism, after previously being diagnosed with pulmonary emboli. Following discharge, district nurses were intended to administer daily tinzaparin injections, but the referral was not received because an obsolete email address was used. The principal concern was that Doreen and her sons were not given sufficiently explicit advice about the potentially fatal consequences of missed medication and were not given the district nursing team’s telephone number or told to call if nurses did not attend.

    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 explicit discharge advice about the fatal consequences of district nursing visits and medication administration not taking place

    Wider context from the report

    “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place. She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day. I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice. I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did. I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission. ”

    Source location

    Doreen Elma STAPLETON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide district nursing contact details and missed-visit escalation instructions at discharge

    Wider context from the report

    “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place. She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day. I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice. I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did. I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission. ”

    Source location

    Doreen Elma STAPLETON · 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

    Write to doctors, senior nurses and pharmacists highlighting learning points for embedding in clinical practice.

    Verbatim wording from the response

    “1) ████████ and I, as Director of Nursing and Patient Experience and Executive Medical Director respectively, will write to our doctors and senior nurses and pharmacists to highlight what we think are the key learning points that arise out of your concerns, so that they can consider how to embed these in their clinical practice from now on.”

    Source location

    Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
    Page 1 · response
    Published 5 March 2017

    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

    Share learning with inpatient pharmacists to support patients’ understanding of medication significance at discharge.

    Verbatim wording from the response

    “5) I have asked our Chief Pharmacist to share this learning with all pharmacists on our inpatient wards so that they can make an important contribution to ensuring that patients understand the significance of their medication on discharge.”

    Source location

    Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
    Page 2 · response
    Published 5 March 2017

    Open published response

  6. Brighton and Hove

    AI-generated summary

    Marion Rose HOWES · 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

    Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

    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 patients with discharge-summary copies and an understanding of their significance

    Wider context from the report

    “(1) Discharge summaries from the hospital These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital. In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge. ”

    Source location

    Marion Rose HOWES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. South London

    AI-generated summary

    Nicola Matthews · 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

    Nicola Matthews took an overdose of medication after leaving hospital on 15 October 2010 and was found unrousable at her partner’s home in the early hours of 16 October, later being pronounced dead in hospital. The principal concern was that decisions about her discharge, including follow-up arrangements and the nature and quantity of medication supplied, were unclear and inadequately documented or communicated.

    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

    Unclear and undocumented follow-up arrangements for discharged patients

    Wider context from the report

    “My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital. The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner. In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged. I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented. ”

    Source location

    Nicola Matthews · Prevention of Future Deaths report
    Page 3 · 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