Recurring concern

Unreliable clinical review and authorisation of discharge decisions

First to latest report 2 Apr 2014 — 11 Jan 2026

Reports that mention this concern
20
Times this concern has been raised
24
Stated actions linked to this concern
18

What this concern includes

Includes failures in the clinical review and authorisation of hospital, mental-health or ambulatory-care discharge decisions, including failure to reconsider discharge after a material change in presentation, failure to obtain required psychiatrist or senior clinician review, and decisions made or potentially made by non-clinical or otherwise unauthorised personnel.

What is not included
  • Excludes discharge timing, transport, accommodation, medication, information and post-discharge follow-up failures where the clinical review or authorisation of the discharge decision is not the deficient control.
  • Excludes routine clinical disagreement with a discharge decision when the decision received appropriate, timely and accountable clinical review.
  • Excludes generic clinical staffing, documentation or communication deficiencies unless they directly result in discharge decisions proceeding without required clinical review or authorisation.
  • Excludes admission, transfer and treatment decisions that are not decisions about discharge.

Reports and published responses 20 reports

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

  1. Kent and Medway

    AI-generated summary

    Mark Stuart VIDLER · 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 Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.

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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

    Pre-determined HTT discharge decisions before patient assessment

    Wider context from the report

    “(4) I heard evidence that the decision to discharge Mark from the HTT was made at a multi-disciplinary team (MDT) meeting prior to the HTT nurse visiting Mark on 6 May 2025. This raises the concern that the decision was pre-determined. I heard no evidence that this situation has changed. ”

    Source location

    Mark Stuart VIDLER · Prevention of Future Deaths report
    Page 3 · concerns

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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

    Hold twice-weekly multidisciplinary discussions with community services about patient care, including planned Home Treatment Team discharges.

    Verbatim wording from the response

    “The HTT have initiated a twice weekly MDT discussions with Community services which focuses discussion on aspects of individual patients care including those patients for whom discharge is planned from HTT. This allows for the wider support system to debate and consider the decision to discharge. In addition, as part of the Trusts ongoing development, of understanding and managing risk with our patients, a risk assessment is completed at discharge. If the clinician completing the risk assessment identifies a deterioration in mental state this can and should delay that decision- the team have a mechanism for discussion and decision making regarding clinical care, on a daily basis, and access to a Consultant Psychiatrist for advice and guidance in complex cases.”

    Source location

    Response from Kent and Medway NHS Mental Health Trust
    Page 3 · response
    Published 21 January 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.

    Verbatim wording from the response

    “The Rapid Response Team will have senior clinical input into these interface forums where decisions impacting on patient care can be discussed and decisions made clinically to ensure the person has an agreed discharge plan that promotes clinical safety and is based on senior clinical consideration. The revised Standard Operating Procedure will detail that MHT+ colleagues including medics must be invited to these forums to assist with community treatment planning and will be audited 3 monthly to ensure quality, patient safety and positive patient outcomes agreed across the interface of services.”

    Source location

    Response from Kent and Medway NHS Mental Health Trust
    Page 3 · response
    Published 21 January 2026

    Open published response

  2. Shropshire, Telford and Wrekin

    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.

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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 obtain cardiology review of discharge appropriateness

    Wider context from the report

    “(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate. ”

    Source location

    Lynn SILCOCK · Prevention of Future Deaths report
    Page 2 · concerns

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    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
    Page 1 · response
    Published 19 December 2025

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    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
    Page 1 · response
    Published 19 December 2025

    Open published response

  3. North London

    AI-generated summary

    Sidi Chax Bojang · 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

    On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.

    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 obtain psychiatrist review before discharge

    Wider context from the report

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. ”

    Source location

    Sidi Chax Bojang · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Discharge decisions falling to a senior psychiatric nurse

    Wider context from the report

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. ”

    Source location

    Sidi Chax Bojang · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Milton Keynes

    AI-generated summary

    Brian Thomas RINGROSE · 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

    Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

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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 provide timely final medical review before formal discharge

    Wider context from the report

    “Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

    Source location

    Brian Thomas RINGROSE · Prevention of Future Deaths report
    Page 4 · concerns

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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 the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.

    Verbatim wording from the response

    “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

    Source location

    Response from Milton Keynes University Hospitals
    Page 8 · response
    Published 4 August 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.

    Verbatim wording from the response

    “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

    Source location

    Response from Milton Keynes University Hospitals
    Page 8 · response
    Published 4 August 2025

    Open published response

  5. Berkshire

    AI-generated summary

    Lorraine Sandra Parker · 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

    Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.

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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 take postoperative CRP results into account in discharge and scanning decisions

    Wider context from the report

    “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024. 3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision. 4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan. ”

    Source location

    Lorraine Sandra Parker · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.

    Verbatim wording from the response

    “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.”

    Source location

    Response from The Association of Coloproctology of Great Britain and Ireland
    Page 1 · response
    Published 24 April 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Direct South East Clinical Quality colleagues to engage with the relevant ICB or Trust and seek assurance that learning from Lorraine’s case has been taken.

    Verbatim wording from the response

    “NHS England notes the local delays in reporting experienced by Lorraine, who was sent home on 31 January 2024 without a post-operative scan despite an elevated CRP, together with the misreporting of the CT scan in February 2024. Clinical Quality colleagues in the South East region have been made aware of your Report and asked to engage with the relevant Integrated Care Board / Trust on the details of Lorraine’s case and to seek assurance that learnings have been taken.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 April 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.

    Verbatim wording from the response

    “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.”

    Source location

    Response from The Association of Coloproctology of Great Britain and Ireland
    Page 1 · response
    Published 24 April 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.

    Verbatim wording from the response

    “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.”

    Source location

    Response from Royal College of Surgeons
    Page 1 · response
    Published 24 April 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.

    Verbatim wording from the response

    “With regard to concerns about guidance for clinicians, the NICE guideline on colorectal cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer by providing evidence-based recommendations on the management of both local disease and metastatic (secondary) cancer. It covers which interventions should be used for different types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and other treatments.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 April 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS Trusts are responsible for ensuring staff competence and should review their clinical protocols following the case.

    Verbatim wording from the response

    “With regard to concerns about clinical judgement, NHS Trusts are responsible for ensuring staff are sufficiently competent to deliver care. Accordingly, the Trust in question should consider their protocols in the wake of this case. The CQC has passed details of the case to the relevant inspection team for Royal Berkshire Hospital for further consideration.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 April 2025

    Open published response

  6. Manchester South

    AI-generated summary

    Rhys Lennon Hill · 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

    Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.

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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

    Unclear governance of safe discharge decisions from the neurosurgical ward

    Wider context from the report

    “7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear. The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician; ”

    Source location

    Rhys Lennon Hill · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.

    Verbatim wording from the response

    “This response focuses on the issues raised in your Report within the remit of NHS England national policy and programmes. Concern numbers one to seven in your Report fall under the remit of Lancashire Teaching Hospitals NHS Foundation Trust. I note that you have also addressed your Report to the Trust, who are the appropriate organisation to respond. NHS England has requested to be sighted on this and will carefully consider their response to the coroner. My regional Quality colleagues within the North West have been engaging with Lancashire and South Cumbria Integrated Care Board (ICB) to seek assurance for the local concerns raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 19 January 2024

    Open published response

  7. Inner West London

    AI-generated summary

    Mr Oleg Khala · 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

    Mr Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

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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 resolve differing psychiatric team assessments before discharge

    Wider context from the report

    “5. That where psychiatric teams differ in their assessments such as CATT and psychiatric liaison, as occurred here, patients are not discharged until opinion is soft from the on-call consultant and re-discussion taken place between those with differing views. ”

    Source location

    Mr Oleg Khala · Prevention of Future Deaths report
    Page 4 · concerns

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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 discuss CATT discharge and admission patients with the on-call psychiatrist

    Wider context from the report

    “4. That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately. ”

    Source location

    Mr Oleg Khala · 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

    Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.

    Verbatim wording from the response

    “CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge.”

    Source location

    Response from West London NHS Trust
    Page 4 · response
    Published 10 July 2023

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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

    Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.

    Verbatim wording from the response

    “The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.”

    Source location

    Response from West London NHS Trust
    Page 6 · response
    Published 10 July 2023

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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

    Work with North West London partners to implement clinical escalation protocols for clinical disagreement.

    Verbatim wording from the response

    “Where a joint assessment and decision is not possible, the person(s) completing the assessment will communicate and discuss and agree the findings with the referrer, service user and within the multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours and on-call psychiatric registrar (approved under section 12 of the Mental Health Act) and consultant) to provide guidance or supplementary assessment in the event of clinical disagreement has been re-communicated to teams, and will be incorporated into work we are doing with partners across North West London to implement clinical escalation protocols.”

    Source location

    Response from West London NHS Trust
    Page 6 · response
    Published 10 July 2023

    Open published response

  8. Manchester South

    AI-generated summary

    Benedict Peters · 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

    Benedict Peters was found dead at his parents’ home on 12 November 2022, after being discharged from the Manchester Royal Infirmary Ambulatory Care Unit the previous day following assessment for chest pain, shortness of breath, sore throat and an aching arm. The inquest found that he died from haemopericardium and acute aortic dissection, with a narrative conclusion referring to complications from an undiagnosed underlying heart defect. Concerns included his discharge without an in-person doctor’s review despite his symptoms, age and family history, and the absence of a Trust policy or protocol governing such discharges.

    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 policy or protocol governing discharge from the Ambulatory Care Unit without medical review

    Wider context from the report

    “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor. It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place. ”

    Source location

    Benedict Peters · 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 conduct an in-person medical review before discharge from the Ambulatory Care Unit

    Wider context from the report

    “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor. It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place. ”

    Source location

    Benedict Peters · 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

    Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.

    Verbatim wording from the response

    “2) “No policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place””

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 2 · response
    Published 17 May 2023

    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

    Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.

    Verbatim wording from the response

    “Mr Peters had been seen and assessed by a Physician Associate (PA), these are professional practitioners working under the aegis of the Royal College of Physicians of London which has produced guidance regarding their responsibilities and scope of practice (https://www.rcplondon.ac.uk/news/fact-finding-physician-associates). Within Manchester University NHS Foundation Trust (MFT), PAs work within an agreed governance framework (enclosed). This has the effect that PAs are not independent practitioners (paragraph 12.7) but work under the delegated authority of a consultant (paragraph 14.2). It is the responsibility of the supervising consultant to ensure that the level of supervision is appropriate to the knowledge and skills of each individual PA.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 2 · response
    Published 17 May 2023

    Open published response

  9. Nottinghamshire

    AI-generated summary

    Jacob · 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

    Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.

    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 named or responsible consultant review before child discharge

    Wider context from the report

    “2. Lack of Named/Responsible Consultant review prior to a child’s discharge ”

    Source location

    Jacob · 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

    Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.

    Verbatim wording from the response

    “• In addition to the audit process, the Divisional Director of Nursing for Children & Neonates and the Matron for Children’s Services have developed an assurance tool, which is being completed weekly for a period of 12 weeks, auditing approximately 5 sets of clinical records every week from each acute area. Unlike the sepsis audit the assurance tool is not exclusive to patients with a clinical diagnosis of sepsis. The tool is designed to monitor the following which were areas of concern noted at the inquest:”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 3 August 2021

    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

    Consultant handovers, case discussion and retrospective attendance-note review provide sufficient safeguards for children discharged without admission.

    Verbatim wording from the response

    “All admitted paediatric patients are discussed with the consultant on service at each morning and evening handover as a routine practice across both sites, therefore, all admitted children are reviewed regularly by a Consultant during their admission. Patients referred that are deemed not to require admission following assessment by the ST4-8 Junior Doctor may be discussed with/reviewed by the Consultant of the week”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 5 · response
    Published 3 August 2021

    Open published response

  10. Manchester City

    AI-generated summary

    Charlotte Elizabeth Jacobs · 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

    Charlotte Jacobs suffered an accidental fall at home on 11 October 2016, developed a deep tissue injury and sacral ulcer, later suffered a stroke, and died from heart failure and related disease on 31 October 2016. Concerns included the failure to assess her capacity to refuse treatment, fluids and nutrition, an inappropriate transfer to a psychiatric ward while she was physically unwell, continuing uncertainty about the appropriateness of such transfers, and incomplete transfer 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 learn from findings that a discharge or transfer should not take place

    Wider context from the report

    “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place. 2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team. 3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation. 4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016). In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths. ”

    Source location

    Charlotte Elizabeth Jacobs · Prevention of Future Deaths report
    Page 2 · 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