Recurring concern

Unsafe medication management during hospital-to-care-home transitions

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First reported 2 Feb 2021•Latest report 15 Oct 2025

Definition

What this concern includes

Includes failures in the hospital-to-care-home medication-management process, including transfer of medication information, reconciliation and recording of changes, confirmation of the receiving home's ability to administer medicines, and timely clarification or escalation when arrangements are unclear.

Not included

Excludes medication-management failures unrelated to a hospital-to-care-home transition.
Excludes generic staffing, training, policy, documentation or communication deficiencies unless they are specifically tied to medication management during the transition.
Excludes failures concerning discharge arrangements that do not materially involve medication safety.
Excludes ordinary prescribing or administration errors occurring after the transition when no transition-related control or information failure is identified.

Reports: 2
Individual concerns: 3
Date range: 2021–2025
Stated actions: 5

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Care UK1

Norfolk and Norwich University Hospital1

Norfolk County Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

15 Oct2025
Sunderland
Concerns raised2
1. Failure to clarify medication changes before continued administration
2. Lack of clear procedures for medication management when a discharge letter cannot be located
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
  Stated by Care UKStated completed
2. Action
  Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
  Stated by Care UKStated completed
3. Action
  Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.
  Stated by Care UKStated completed
1. Action
  Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
  Stated by Care UKStated planned
2. Action
  Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.
  Stated by Care UKStated in progress
AI-generated summary

Mr Thompson Elliott · 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

Thompson Elliott, a care home resident, was admitted to hospital with chest pains and discharged with changed opioid medication. Because the discharge letter could not be located, both old and new opioids were administered, resulting in an overdose; he later contracted influenza A in hospital and died after respiratory failure. The principal concerns were unclear procedures, inadequate medication recording and administration, and inconsistent staff decisions when discharge information was unavailable.

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 clarify medication changes before continued administration
Wider context from the report
“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”
Source location
Mr Thompson Elliott · 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
Lack of clear procedures for medication management when a discharge letter cannot be located
Wider context from the report
“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”
Source location
Mr Thompson Elliott · 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
Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.

Verbatim wording from the response
“To remind staff, a visual flow chart has been introduced at the care home to provide clear, step-by-step guidance for staff involved in supporting residents returning from hospital where there is no accompanying discharge letter to support changes in medication. A copy of this flow chart, which has been shared and discussed with staff to embed awareness of it, accompanies this letter (enclosure 1). This flowchart is laminated and attached to the medication keys as an immediate prompt to staff. Additionally, there are copies of this flow chart in poster format on the wall of the care home's treatment room and there is a further copy contained within a dedicated discharge file held in the Deputy Manager's office. This dedicated file has been brought in following this case and contains the flow chart prompt and copies of Care UK's relevant up-to-date policies to which I refer below.”

Source location
Response from Care UK
Page 2 · response
Published 20 October 2025
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
Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.

Verbatim wording from the response
“The care home leadership has reinforced Care UK's 'Admissions and Discharge Policy' (enclosure 2) and the 'How to Guide - Supporting a Resident Returning from Hospital' (enclosure 3) as well as the 'Medications Management Policy' (enclosure 4). These documents provide clear guidance to staff as to what to do in circumstances where a resident arrives and/or returns to the care home from hospital and there is insufficient/absent information regarding their discharge and attendant medications. All staff have completed a mandatory "read and sign" process to confirm that they have read and understood these documents, all of which have been discussed with staff as part of further refresher training sessions undertaken.”

Source location
Response from Care UK
Page 2 · response
Published 20 October 2025
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
Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.

Verbatim wording from the response
“Discussion and further refresher training with all relevant staff has emphasized the need to ensure home management is informed immediately of any concerns regarding residents returning from hospital and that checks are undertaken with the hospital. The training has reinforced that if the hospital cannot be reached for an answer, colleagues should check with the GP and failing that contact the 111 service.”

Source location
Response from Care UK
Page 1 · response
Published 20 October 2025
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
Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.

Verbatim wording from the response
“The Home Manager and/or Deputy will ensure that any imminent or new discharges to the care home are discussed at the daily 10@10 meetings and weekly clinical review meetings to ensure staff are aware of the discharges, the relevant information is obtained and any matters requiring follow-up are actioned. In addition, it is also important to note that there is always a member of the management team available (seven days a week) and so at any time the discharge process is taking place, there are senior staff available to help deal with/advise on any issues arising with the discharge.”

Source location
Response from Care UK
Page 2 · response
Published 20 October 2025
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
Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.

Verbatim wording from the response
“The care home has continued to work closely with the Trusted Assessor team at the hospital which discharged Mr Elliott to try to streamline communication/interaction in relation to discharges. The aim is to ensure all documents are securely and promptly shared including via NHS email if possible to support timely and safe transitions of care from hospital to the care home. This work is ongoing but the care home and its hospital partners share a commitment to best practice to achieve these aims. As noted above, the Home Manager has held meetings with the local hospital's Trusted Assessors to discuss the care home's discharge policies to ensure agreement and buy in to the process.”

Source location
Response from Care UK
Page 3 · response
Published 20 October 2025
Open published response
2 Feb2021
Norfolk
Concerns raised1
1. Discharge of patients with medicines that the receiving care home cannot administer
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The Trust disputes that Mr Yemm was discharged without warning or without arrangements for insulin administration and supervision.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Michael Yemm · 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

Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.

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
Discharge of patients with medicines that the receiving care home cannot administer
Wider context from the report
“The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff. ”
Source location
Michael Yemm · Prevention of Future Deaths report
Page 2 · 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
The Trust disputes that Mr Yemm was discharged without warning or without arrangements for insulin administration and supervision.

Verbatim wording from the response
“Mr Yemm was started on insulin during the May 2020 admission. A District Nurse referral was made on discharge as Mr Yemm was unable to manage his own injections. On 17 June 2020 a “verbal handover” was given to Melton House including confirmation that the District Nurse referral had been completed in respect of Mr Yemm’s “insulin administration”.”

Source location
2021-0024-Response-from-Norfolk-and-Norwich-University-Hospital-Redacted
Page 2 · response
Published 4 February 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to clarify medication changes before continued administration

Lack of clear procedures for medication management when a discharge letter cannot be located

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Discharge of patients with medicines that the receiving care home cannot administer

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 5

Respondent positions 1