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. Norfolk

    AI-generated summary

    Brian Robert HAVARD · 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 Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.

    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 exercise professional curiosity in high-risk discharge decisions

    Wider context from the report

    “1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient. ”

    Source location

    Brian Robert HAVARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. East London

    AI-generated summary

    Brenda Kathleen GOWAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to reconsider the care plan when night-time circumstances changed

    Wider context from the report

    “(3) The discharge plan was based upon Brenda being settled at night time. When the family reported that this had changed and that Brenda was “up a lot” – the care plan for Brenda should have been re-considered. ”

    Source location

    Brenda Kathleen GOWAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  3. West London

    AI-generated summary

    Henry Curtis-Williams · 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

    Henry Curtis-Williams died from hanging at Acton Cemetery on 17 May 2018; the inquest conclusion was hanging and suicide. Concerns included inadequate contemporaneous recording, discharge by junior doctors without prior senior review, and informal communication without records of important messages.

    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 require senior clinical reference before discharge by very junior doctors

    Wider context from the report

    “(2) There was an acceptance that patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though Henry had been admitted after being assessed by 2 Section 12 approved doctors and an Appointed Mental Health Professional who felt he needed a prolonged inpatient stay. ”

    Source location

    Henry Curtis-Williams · 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

    Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.

    Verbatim wording from the response

    “You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has”

    Source location

    2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 5 April 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.

    Verbatim wording from the response

    “You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has”

    Source location

    2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 5 April 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide junior doctors with discharge-related teaching during Trust induction.

    Verbatim wording from the response

    “provided learning to Consultant Psychiatrists and teaching will be provided to junior doctors as part of their induction to the Trust.”

    Source location

    2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 5 April 2019

    Open published response

  4. North West Wales

    AI-generated summary

    Simon Willans · 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

    Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.

    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 decisions made without involvement of a clinician responsible for the patient's care

    Wider context from the report

    “(3) Mr Willans appears to have been discharged by a Nurse Practioner ████████ who had no involvement in the care of Mr Willans. ████████, or any other doctor does not appear to have been involved in the discharge of Mr Willans. Nurse Practitioner Jones adds another diagnosis to the GP letter over and above that of her colleague despite never seeing the patient. ”

    Source location

    Simon Willans · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Nuala Seddon · 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

    Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.

    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 clinical staff make discharge decisions

    Wider context from the report

    “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation. ”

    Source location

    Nuala Seddon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Brighton and Hove

    AI-generated summary

    Mr Raymond Frank POLLARD · 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 Raymond Frank Pollard was admitted to hospital with community-acquired pneumonia and respiratory and renal problems, including metabolic acidosis and high potassium levels. He was discharged to a rehabilitation nursing home without further arterial blood gas checks, a further doctor review, or reassessment before discharge, but became extremely unwell and required urgent hospital treatment. The principal concerns were that the discharge decision was poorly informed, that he was not reviewed for suitability for discharge, and that the failed discharge seriously compromised him.

    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 medically review suitability for discharge

    Wider context from the report

    “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition. (2) The patient was not seen again by a doctor or reviewed as to suitability for discharge. (3) As a result the discharge failed and this failure seriously compromised Mr Pollard. ”

    Source location

    Mr Raymond Frank POLLARD · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Poorly informed discharge decision-making

    Wider context from the report

    “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition. (2) The patient was not seen again by a doctor or reviewed as to suitability for discharge. (3) As a result the discharge failed and this failure seriously compromised Mr Pollard. ”

    Source location

    Mr Raymond Frank POLLARD · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the identified care concerns to identify required improvements and share learning with Respiratory Medicine staff.

    Verbatim wording from the response

    “I am very sorry to read about the circumstances of Mr Pollard’s death and the concerns which you have highlighted. These issues have been reviewed by senior medical and nursing staff, including the Trust’s Head of Nursing, Discharge and Partnerships, to identify improvements required within the Directorate and to ensure that learning from this case is shared with staff in Respiratory Medicine.”

    Source location

    2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
    Page 1 · response
    Published 19 February 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

    Raise the discharge-related events through Directorate clinical governance meetings and staff training and awareness sessions.

    Verbatim wording from the response

    “Events surrounding Mr Pollard’s discharge are being raised with nursing and medical staff through the Directorate clinical governance meetings and training/awareness sessions for staff which will continue this year, as a means of ensuring learning. These will focus on ensuring adherence to existing policies in respect of:”

    Source location

    2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
    Page 2 · response
    Published 19 February 2017

    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

    Automatic medical review after discharge decisions is unnecessary because board rounds, nurse escalation and existing discharge policies provide sufficient safeguards.

    Verbatim wording from the response

    “I do understand your concern about continuing medical review of complex patients following a decision that they are ready for discharge. The Trust is committed to ensuring that all available medical resources are used as effectively as possible; this includes prioritising those patients who will most benefit from direct medical input, rather than providing automatic medical review of all patients. The medical team does review the progress of all MRFD patients on the daily “board round” and will follow up any issues identified either as a result of that process, or arising from any request from clinical colleagues, including nurses. It is very important, therefore, that existing Trust policies are followed from the point when the patient’s discharge becomes nurse-led, in responding to changes in patients’ symptoms and appropriately requesting medical input.”

    Source location

    2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
    Page 2 · response
    Published 19 February 2017

    Open published response

  7. Manchester West

    AI-generated summary

    Helen England · 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

    Helen England, who had bipolar affective disorder and was subject to a Community Treatment Order, was found hanging in her home on 26 December 2013 after recent self-harm, hospital discharge and concerns about her safety. The principal concern was that there was no protocol or guidance for mental health nurses on whether to refer discharge decisions to a doctor, particularly when a patient subject to a Community Treatment Order had attended or been admitted to hospital following self-harm.

    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 protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm

    Wider context from the report

    “There was no protocol nor any guidance in place for Mental Health Nurses at the 5 Boroughs NHS Partnership Foundation Trust to follow when considering whether or not to refer to a Doctor a decision to discharge a patient, following an attendance at, or admission to, an acute Hospital consequent upon an episode of self-harm, particularly when the patient is subject to a Community Treatment Order imposed under the terms of the Mental Health Act. ”

    Source location

    Helen England · 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

    Amend the Community Treatment Order Procedure to address the identified concerns.

    Verbatim wording from the response

    “I am writing to inform you that although the Regulation 28 was not aimed specifically at the Trust I would like to confirm that our Community Treatment Order Procedure has been amended in light of your concerns and the processes for communicating this to our staff is underway.”

    Source location

    Helen-England-Response
    Page 2 · response
    Published 16 March 2016

    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

    Communicate the amended Community Treatment Order Procedure to staff.

    Verbatim wording from the response

    “I am writing to inform you that although the Regulation 28 was not aimed specifically at the Trust I would like to confirm that our Community Treatment Order Procedure has been amended in light of your concerns and the processes for communicating this to our staff is underway.”

    Source location

    Helen-England-Response
    Page 2 · response
    Published 16 March 2016

    Open published response

  8. Manchester (North)

    AI-generated summary

    Susan Beverley George · 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

    Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

    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 review discharge decisions after material changes in patient presentation

    Wider context from the report

    “1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled. ”

    Source location

    Susan Beverley George · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.

    Verbatim wording from the response

    “The current discharge protocol will be reviewed to ensure it is still reflective of all required processes and add a note of guidance to staff should they be faced with a similar situation.”

    Source location

    Susan-George-Response
    Page 4 · response
    Published 29 February 2016

    Open published response

  9. Manchester City

    AI-generated summary

    Craig Douglas 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

    Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

    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 suitably senior psychiatric clinician attendance at discharge case reviews

    Wider context from the report

    “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting. In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented. ”

    Source location

    Craig Douglas Bell · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  10. Black Country

    AI-generated summary

    Mr John Dodd · 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 John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

    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 medically reassess the patient before discharge

    Wider context from the report

    “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

    Source location

    Mr John Dodd · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026