Concerns raised 2
Delays or failures in delivery of ED discharge summaries View source Inadequate information in ED discharge summaries View source
This report raised 3 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.
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David MARRIOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries to patients.
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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 Delays or failures in delivery of ED discharge summaries
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning.
I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” Source location David MARRIOTT · Prevention of Future Deaths report
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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 Inadequate information in ED discharge summaries
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on . Often, they contain inadequate or insufficient information , like the one in this case which did not make clear the steps required of the GP . Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning.
I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” Source location David MARRIOTT · Prevention of Future Deaths report
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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 Complete pharmacy feedback and update the agreed ED discharge-letter template to improve medicines documentation.
Verbatim wording from the response “In the interim, the Trust has already taken feedback and held discussions with GP colleagues to establish the preferred content of e-posted letters for patients discharged from the Emergency Department back to their care, leading to an agreed template. ED colleagues are completing pharmacy team feedback regarding discharged medication documentation to update the agreed template for improved medicines safety and this is expected to be completed by July 2026.
Nevercentre will then require system updates to include a full clinician summary of attendance which will auto generated for those patients discharged directly from ED (as clinically appropriate).” Source location Response from Nottingham University Hospitals NHS Trust
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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 Implement system updates to auto-generate a full clinician summary for appropriate patients discharged directly from ED.
Verbatim wording from the response “In the interim, the Trust has already taken feedback and held discussions with GP colleagues to establish the preferred content of e-posted letters for patients discharged from the Emergency Department back to their care, leading to an agreed template. ED colleagues are completing pharmacy team feedback regarding discharged medication documentation to update the agreed template for improved medicines safety and this is expected to be completed by July 2026.
Nevercentre will then require system updates to include a full clinician summary of attendance which will auto generated for those patients discharged directly from ED (as clinically appropriate).” Source location Response from Nottingham University Hospitals NHS Trust
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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 medical-documentation training, including discharge-summary requirements, through Foundation Doctor induction and Resident Doctor teaching.
Verbatim wording from the response “Education on Medical Documentation
The Trust now provides training on medical documentation as a fixed session in the annual Foundation Doctor Induction and in Resident Doctor teaching, including discharge summaries (applicable Trustwide, not just ED). The materials will be further reviewed and updated prior to the October 2026 delivery in response to this case and will emphasise the importance of robust follow up arrangements and what can reasonably be delivered by community colleagues and what needs to be delivered by NUH (current materials provided in Appendix 7). The Acute Deterioration Improvement Team will also provide an NUH intranet page with the resources.” Source location Response from Nottingham University Hospitals NHS Trust
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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 Review and update medical-documentation training materials to emphasise robust follow-up arrangements before October 2026 delivery.
Verbatim wording from the response “Education on Medical Documentation
The Trust now provides training on medical documentation as a fixed session in the annual Foundation Doctor Induction and in Resident Doctor teaching, including discharge summaries (applicable Trustwide, not just ED). The materials will be further reviewed and updated prior to the October 2026 delivery in response to this case and will emphasise the importance of robust follow up arrangements and what can reasonably be delivered by community colleagues and what needs to be delivered by NUH (current materials provided in Appendix 7). The Acute Deterioration Improvement Team will also provide an NUH intranet page with the resources.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
27 May 2025 Abdirahman Afrah · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to send relevant results and discharge summaries to the GP in time for appointments View source
This report raised 6 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.
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AI-generated summary
Abdirahman Afrah · 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
Abdirahman Afrah developed severe chest pain and attended A&E, but left without being seen by a doctor after a prolonged wait. He later collapsed at home and died in hospital on 4 June 2024 from bleeding caused by a pulmonary vascular malformation. The concerns included prolonged A&E waits, lack of timely medical triage, unclear communication about the urgency of returning to hospital, failure to discuss this directly with a responsible parent, and failure to send results to his GP in time.
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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 send relevant results and discharge summaries to the GP in time for appointments
Wider context from the report “5. When Abdirahman stated that he would be seeing his GP later that afternoon, he asked for the relevant results to be sent to the GP. Neither the results, nor the discharge summary were sent to the GP in time for the appointment . The inquest heard that the A&E doctor did not know how to share such information with the GP .
” Source location Abdirahman Afrah · Prevention of Future Deaths report
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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 junior doctors with dedicated administration time to check results and communicate them to patients and GP practices.
Verbatim wording from the response “Since August 2024 we introduced specific administration time for junior doctors in ED to check results. During this process all resident doctors have been using Accurx to contact patients and GP practices and thus the use of this form of communication has increased significantly.” Source location 2025-0245- Response from Barts Health NHS Foundation Trust
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10 Jun 2024 Margaret Ann PILGRIM · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to communicate identified fractures in discharge information View source
This report raised 3 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.
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Margaret Ann PILGRIM · 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
Margaret Ann Pilgrim died at Princess Alexandra Hospital on 29 June 2023 from congestive cardiac failure and bronchopneumonia, against a background of frailty, after an unwitnessed fall at home caused a fractured clavicle. The fracture was reported on an X-ray during her hospital admission but was not noted on her discharge summary. Concerns included the absence of treatment, pain relief, care-package consideration and fracture-clinic follow-up, and the failure to inform the patient, her family or GP about the fracture.
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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 communicate identified fractures in discharge information
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” Source location Margaret Ann PILGRIM · Prevention of Future Deaths report
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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 Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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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 Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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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 existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
Open published response
12 Apr 2024 Sabina Wood · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3
Lack of a standardized process for creating and completing discharge summaries View source Failure to prepare discharge summaries only when patients are ready for discharge View source Failure of the discharge-summary IT system to verify completion before marking documents complete View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sabina Wood · 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
Sabina Wood was admitted to hospital with abdominal pain, gallstones and possible bile duct stones, underwent an ERCP, and self-discharged against medical advice. She was found unresponsive at home on 27 January 2023 and her death was recorded as a natural death, with acute haemorrhagic pancreatitis and cholelithiasis stated as the medical cause. The principal concern was that a speculative and inaccurate draft discharge summary, prepared before the ERCP and sent to her GP practice, reflected unsafe processes and could pose a risk to future patients.
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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 Lack of a standardized process for creating and completing discharge summaries
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries . I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital .
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Source location Sabina Wood · Prevention of Future Deaths report
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 prepare discharge summaries only when patients are ready for discharge
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge . I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays . This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling .
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Source location Sabina Wood · Prevention of Future Deaths report
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 of the discharge-summary IT system to verify completion before marking documents complete
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete . The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Source location Sabina Wood · Prevention of Future Deaths report
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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 Implement the integrated NPR eDischarge system with auto-population and password safeguards preventing incomplete discharge summaries from being issued.
Verbatim wording from the response “With regard to the IT system in place to provide discharge summaries, to which your concern relates, the Trust are in the process of replacing the current eDischarge product with one integrated system built upon the Trust’s Nexus NPR platform, developed in house by our Application Development Team.” Source location Response from Blackpool Teaching Hospitals
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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 Issue a safety instruction directing staff to take care when pre-populating discharge summaries and avoid prejudging investigation results.
Verbatim wording from the response “In the interim whilst system implementation is brought to completion, the Executive Medical Director will issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need to take care when pre-populating and that clinicians are not to prejudge any investigation results.” Source location Response from Blackpool Teaching Hospitals
Open published response
Concerns raised 1
Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs View source
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.
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AI-generated summary
Sebastian Harry DANIELS · 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
Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.
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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 of ED discharge summaries to clearly identify diagnoses and actions expected from GPs
Wider context from the report “2. The RCA report identified that the format of discharge summaries provided to GPs by the ED department needed to be reviewed to ensure that actions to be undertaken by GPs were clearly identified . The results of this were to be audited.
Following the inquest I was provided with an audit report. This report dated 13/9/21 revealed that the computer system could not be altered as had been hoped and therefore a change of practice was introduced instead. This required clinicians to document actions in a free text section with appropriate flagging for GPs. 20 cases were audited and only half met the standard national guidance and 8 lacked a clear diagnosis & details of what was expected from GPs .
Hampshire Hospital Trust have informed me that further actions are being taken to address these deficiencies. However as it is now a year since the RCA report was prepared and over 2 years since Mr Daniel’s death I am concerned that this action is not being taken swiftly given the risks to patients.
” Source location Sebastian Harry DANIELS · Prevention of Future Deaths report
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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 Require ED clinicians to document significant findings and matters requiring GP attention under a separate heading in discharge summaries.
Verbatim wording from the response “ED clinicians have also been notified that they are required to continue to document significant findings and matters requiring GP attention, under a separate heading within the GP free text notes box, on the Patient First discharge summary. It was felt that compliance of this, underpinned with documented audit, was likely limited due to the turnover of trainee doctors. In order to ensure that all staff remain aware of this requirement the Trust is in the process of updating its junior doctors induction program to include the above changes in the discharge process. This will take effect from the next induction taking place on 6 December 2023.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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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 Update the junior doctors’ induction programme to include the revised discharge-process requirements.
Verbatim wording from the response “ED clinicians have also been notified that they are required to continue to document significant findings and matters requiring GP attention, under a separate heading within the GP free text notes box, on the Patient First discharge summary. It was felt that compliance of this, underpinned with documented audit, was likely limited due to the turnover of trainee doctors. In order to ensure that all staff remain aware of this requirement the Trust is in the process of updating its junior doctors induction program to include the above changes in the discharge process. This will take effect from the next induction taking place on 6 December 2023.” Source location Response from Hampshire Hospitals NHS Foundation Trust
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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 Re-audit a random sample of discharge letters at three and six months to monitor the impact of the changes.
Verbatim wording from the response “In order to monitor the impact of these actions the Trust will re-audit a random sample of discharge letters at three and six months.” Source location Response from Hampshire Hospitals NHS Foundation Trust
Open published response
Concerns raised 1
Failure to communicate medication dosage errors to patients and GPs View source
This report raised 3 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.
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AI-generated summary
JOHN ALFRED ROBERTS · 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
John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.
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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 communicate medication dosage errors to patients and GPs
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” Source location JOHN ALFRED ROBERTS · Prevention of Future Deaths report
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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 procedures did not require reporting a no-harm dosage discrepancy to the GP when no post-discharge GP action was needed.
Verbatim wording from the response “As stated in evidence during the inquest hearing over 12 - 14 April 2023, the dosage discrepancy caused no harm to Mr Roberts and there was no action required by the GP in relation to the dose discrepancy of ████████ doses administered from the 7th-13th June. It is not within our procedures to communicate to the GP incidents that cause no harm to the patient and require no action by the GP following discharge.” Source location Response from Royal Cronwall Hospitals NHS Trust
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3 Mar 2021 Helen Margaret McLean · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2
Failure to transmit discharge summaries to GP practices View source Failure to record the correct GP practice name and identifier on discharge summaries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Helen Margaret McLean · 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 Margaret McLean was without Edoxaban from 5 November 2020 after medication and discharge information were not correctly transferred between hospital, GP practices and her nursing home. She was admitted to hospital with an ischaemic stroke on 18 November 2020 and died on 21 November 2020; the report found it more likely than not that Edoxaban may have prevented the fatal event. A substantive concern was that the discharge summary was not received by the GP practice and contained an incorrect GP practice identifier, with medication-transfer processes also failing to identify the omission.
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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 transmit discharge summaries to GP practices
Wider context from the report “Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition.
” Source location Helen Margaret McLean · Prevention of Future Deaths report
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 record the correct GP practice name and identifier on discharge summaries
Wider context from the report “Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong . (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition.
” Source location Helen Margaret McLean · Prevention of Future Deaths report
Open source report
27 Jan 2021 Norma Bradbury · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Delays in transmitting discharge letters when timely GP involvement is required View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Norma Bradbury · 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
Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.
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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 Delays in transmitting discharge letters when timely GP involvement is required
Wider context from the report “Mrs Bradbury was discharged on 22.02.19.
The discharge letter to her GP instructed a review within 1 week to check Mrs Bradbury’s bloods and blood pressure, and to restart Losartan, and titrate the dose to her blood pressure. The consultant giving evidence at the hearing was clear that he expected this to have commenced within a week of discharge.
The evidence of Mrs Bradbury’s GP was that the discharge letter was not received until 25.02.19. The GP also advised that the delay in receiving discharge letters was very variable, between days and weeks.
I accept that in many cases the discharge letter is no more than a summary of an attendance and requires little or no further action on the part of the GP and the delay is of no consequence. However, where, as here, the discharging hospital requires GP involvement within 1 week of discharge a delay of 3 days in requesting or advising that involvement is not acceptable.
While it was not possible to determine any difference in outcome in Mrs Bradbury’s case there is a risk that such a delay would make a difference.
” Source location Norma Bradbury · Prevention of Future Deaths report
Open source report
11 Nov 2020 Margaret Lilian SALES · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to communicate required follow-up arrangements to GPs at discharge View source
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.
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AI-generated summary
Margaret Lilian SALES · 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
Margaret Lilian Sales, who was frail and had several comorbidities, was admitted to hospital on 13 December 2019 and died on 4 January 2020 after her health deteriorated. Concerns included incomplete records, difficulties contacting on-call medical staff, and a failure to request GP monitoring of her capillary blood glucose after discharge. The inquest concluded that she died from aspiration pneumonia, the cause of which was not clear from the evidence.
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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 communicate required follow-up arrangements to GPs at discharge
Wider context from the report “3. On a previous discharge from hospital, it was noted Mrs Sales had been referred to the Home Enteral Nutrition service for monitoring and follow up and that in situations such as this, requests will be placed with the GP. However, no such request had been placed with the GP. The Discharge Letter in fact stated: "Actions for the GP: No recommendations" . As a result, the GP did not monitor Mrs Sales’ capillary blood glucose following discharge.
” Source location Margaret Lilian SALES · Prevention of Future Deaths report
Open source report
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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 Current practice and guidelines did not indicate that the Trust should recommend home blood glucose monitoring to the GP.
Verbatim wording from the response “At this Trust our Diabetic Specialist Nurses would ensure that the GP was made aware that they had to ensure blood glucose monitoring was done at home if a patient had been put on either Gliclazide or Insulin during an admission. It is true to say that if Mrs Sales had had her blood glucose monitored at home between 6th November and 13 December 2019 her subsequent illness would have become apparent sooner, but in terms of current practice and guidelines there was no indication for us to make such a recommendation to the GP.” Source location 2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
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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 system remains robust, so no further action is proposed regarding home blood glucose monitoring advice.
Verbatim wording from the response “I have heard from our consultant ████████ and also Legal Services Manager that we had not expected this issue to be raised at the inquest, if so we would have taken the opportunity to supply evidence on this point for you at the time from one of our Dietetics or Diabetes team members who deal regularly with referrals to Fresnius and the General Practitioners in Norfolk, Cambridgeshire and Lincolnshire. With hindsight, perhaps our RCA could have gone into more detail on that point; but presently we think that the system remains robust and with no discourtesy intended do not propose to take any further action on this point at the present time.” Source location 2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Open published response
23 Oct 2020 Sean Robert Steven Owen · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2
Lack of quality assurance of discharge summary letters View source Discharge summary letters failing to communicate significant clinical risks and incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sean Robert Steven Owen · 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
Sean Robert Steven Owen had a history of treatment-resistant paranoid schizophrenia and was recognised as being at significant risk if non-compliant with medication. After medication monitoring arrangements broke down, he self-inflicted a penetrating neck injury on 3 June 2019 and died on 14 June 2019 from his injuries and a chest infection. The report raised concerns that his discharge letter omitted significant information about overdoses, suicidal thoughts and the risks associated with medication non-compliance, and that there was no quality assurance system for such letters.
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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 Lack of quality assurance of discharge summary letters
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care . The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician . It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.
” Source location Sean Robert Steven Owen · Prevention of Future Deaths report
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 Discharge summary letters failing to communicate significant clinical risks and incidents
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission ; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance .
” Source location Sean Robert Steven Owen · Prevention of Future Deaths report
Open source report
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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 Check and discuss new trainees’ admission and discharge summaries during their first month, with senior-doctor review before discharge.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
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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 Incorporate documentation review into trainees’ weekly supervision.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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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 Audit the revised admission and discharge summary process.
Verbatim wording from the response “The revised process will be subject to an audit.” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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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 Provide all new medical trainees with training on admission and discharge summary standards and processes.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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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 Issue new trainees laptops and require admission and discharge summaries to be maintained as live documents throughout patients’ admissions.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
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Includes dedicated failures of the hospital discharge-summary process that affect the accuracy, completeness, finalisation, quality assurance or timely transmission of summaries to GPs.
