27 May 2026 Abigail Louise SMITH · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to accurately record changes in mental health diagnosis in discharge summaries View source
This report raised 7 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.
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
Abigail Louise SMITH · 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
Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.
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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 accurately record changes in mental health diagnosis in discharge summaries
Wider context from the report “1. Abbi spent most of her adult life detained and over 18 months in a specialist Tier 4 mental hospital having been transferred there by her local mental health trust. The Tier 4 specialist team agreed that Abbi did not have a personality disorder. This was a significant change for Abbi and was not accurately set out in the discharge summary.
” Source location Abigail Louise SMITH · Prevention of Future Deaths report
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2 Apr 2026 David ABBOTT · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Inadequate recording of important discharge advice View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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David ABBOTT · 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 ABBOTT underwent surgery at West Suffolk Hospital on 25 October 2023 and was discharged the following day with advice that he interpreted as meaning he should not mobilise. He remained immobile for four days, subsequently developed deep vein thrombosis and pulmonary embolism, and died in cardiac arrest at home on 29 November 2023. Concerns included potentially incorrect discharge advice, inadequate recording of important advice, and ineffective communication between hospital staff, patients and families.
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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 recording of important discharge advice
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge . If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error.
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
” Source location David ABBOTT · Prevention of Future Deaths 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 Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.
Verbatim wording from the response “Since 2024, a standardised discharge summary process has been implemented within the Trust. This utilises #tag functionality, allowing clinicians to insert pre-approved, standardised advice directly into discharge documentation.” Source location Response from West Suffolk 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 Train junior doctors during induction to use standardised discharge-summary #tags.
Verbatim wording from the response “Junior doctors receive training on the use of #tags during their induction, ensuring early awareness and consistent application in clinical practice.” Source location Response from West Suffolk NHS Foundation Trust
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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 Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.
Verbatim wording from the response “To address this, consultants have been requested to take ownership of the discharge process and provide check and challenge where appropriate of draft discharge letters.” Source location Response from West Suffolk NHS Foundation Trust
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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 Rectify digital barriers and implement digital enablers for producing discharge letters.
Verbatim wording from the response “This incident has reinforced the importance of clear verbal and written communication at discharge. Improving the quality of discharge letters has been a project over the last 18 months led by the Associate Medical Director ████████. This has focused on initially identifying the barriers and the work to address them.” Source location Response from West Suffolk 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 Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.
Verbatim wording from the response “The digital team have now rectified the digital barriers and have tried to implement the enablers. We have also put in place methods to ensure compliance can be monitored by Clinical Directors and Clinical Leads. It is advised that this data should be discussed at departmental and divisional governance meetings.” Source location Response from West Suffolk NHS Foundation Trust
Open published response
1 Aug 2025 Brian Thomas RINGROSE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Discharge documentation liable to be misinterpreted as an official discharge notice View source Ambiguous and inadequately communicated discharge criteria View source
This report raised 20 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
Brian Thomas RINGROSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge documentation liable to be misinterpreted as an official discharge notice
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on . This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 Ambiguous and inadequately communicated discharge criteria
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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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 Amend the police-custody discharge SOP to reflect current Emergency Department and Thames Valley Police processes.
Verbatim wording from the response “This concern refers to a Standard Operating Procedure (Police Custody – Care in and Discharge from ED) which was created using the Royal College of Emergency Medicine Guideline of the same name. I can assure you that it was not created in haste, but had not been updated to reflect work with Thames Valley Police which had continued to evolve and develop local processes and procedures after the guidelines had been published as a local SOP.” Source location Response from Milton Keynes University 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 Implement the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.
Verbatim wording from the response “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.” Source location Response from Milton Keynes University Hospitals
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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 Roll out Dynamic Documentation to the Emergency Department with associated discharge-process training and awareness activity.
Verbatim wording from the response “Discharge summaries are also created in eCare for inpatients (adult and paediatric), day-cases and maternity cases. All currently use the older DEPART tool but the creation of the discharge summary and discharging of the patient from the system are carried out separately. Overtime we would expect all areas to migrate onto the newer Discharge Workflow mPage and associated Dynamic Documentation.” Source location Response from Milton Keynes University 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 Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.
Verbatim wording from the response “This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.” Source location Response from Milton Keynes University 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 Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.
Verbatim wording from the response “This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.” Source location Response from Milton Keynes University Hospitals
Open published response
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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 Reiterate Toxbase guidance to Emergency Department clinicians and provide a quick guide through the Radar documentation system.
Verbatim wording from the response “Brian should not have been discharged. This is accepted and actions described above have been taken to mitigate the risk of a similar event occurring again. Toxbase guidelines have been reiterated to all Emergency Department clinicians, with a quick guide available on the Radar documentation system.” Source location Response from Milton Keynes University Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.
Verbatim wording from the response “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.” Source location Response from Milton Keynes University Hospitals
Open published response
Concerns raised 1
Failure to record an inpatient fall on the discharge letter View source
This report raised 8 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
Hazel Gambles · 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
Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.
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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 record an inpatient fall on the discharge letter
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 Add a mandatory discharge-summary question covering inpatient falls and other safety incidents, and monitor it during implementation.
Verbatim wording from the response “As a Trust, we have now added a mandatory question to the inpatient discharge summary to ask whether the patient has had a fall, VTE (Venous Thromboembolism), pressure ulcer or any other incident. This will prompt clinicians to consider whether any of these have occurred and if so, it will be clear on the discharge summary. This will be monitored throughout the implementation stage, to ensure effectiveness.” Source location Response from Rotherham NHS Foundation Trust
Open published response
Concerns raised 1
Non-uniform hospital discharge notes View source
This report raised 1 other concern. 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
Patricia CURTIS · 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
Patricia Curtis underwent complex cardiac surgery and was transferred to Bedford Hospital, where she deteriorated rapidly and died from a haemothorax identified at post-mortem examination. The report states that a haemothorax was not included in the differential diagnosis when clinical signs first appeared. It also raises concern that non-uniform hospital discharge notes may result in essential information being unavailable after transfer between hospitals, potentially delaying life-saving care and treatment.
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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 Non-uniform hospital discharge notes
Wider context from the report “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment.
” Source location Patricia CURTIS · Prevention of Future Deaths report
Open source report
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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 Responsibility for individual hospital discharge policies lies with individual NHS trusts.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Individual trusts are responsible for their own discharge policies. I am therefore grateful to NHS England for advising that, since the report, they have engaged with Royal Papworth Hospital NHS Foundation Trust. I welcome the steps taken by the trust’s Discharge Planning Group around involvement of next of kin in patient transfers. I look forward to engaging with NHS England to understand how this develops.” Source location Response from DHSC
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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 Individual NHS Trusts are responsible for their own hospital discharge policies.
Verbatim wording from the response “Individual Trusts are responsible for their own discharge policies. However, the Hospital Discharge Service guidance and operating model, published by the Department of Health and Social Care (DHSC) in August 2020 and last updated in January 2024, details the national discharge requirements for all NHS Trusts, community interest companies, private care providers of acute care, community beds and community health services and social care staff in England. The guidance, which is based on successful discharge to assess principles, aims to ensure that all individuals are discharged from hospital in a safe, appropriate and timely way.” Source location Response from NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Royal Papworth Hospital reported no concerns about the quality or format of its discharge summaries.
Verbatim wording from the response “NHS England has engaged with the Royal Papworth Hospital NHS Foundation Trust regarding your Report. We note that, in response to your concerns, their Discharge Planning Group have taken steps to improve their processes for ensuring that next of kin are updated on patient transfers. They advise that there were no concerns regarding the quality or format of their discharge summaries.” Source location Response from NHS England
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12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to provide crisis information at discharge View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Mr David Thompson · 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 David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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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 provide crisis information at discharge
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided .
” Source location Mr David Thompson · 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 Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.
Verbatim wording from the response “Priory Hospital Dorking are to evidence safe discharge planning in accordance with Priory policy H02 Admission, Transfer and Discharge - to include completion of a clinical entry, updated risk assessment on discharge and issue all patients with a crisis card with” Source location Response from Priory Group
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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 crisis cards at discharge by ordering replacement stock and using written or telephone-stored crisis numbers while awaiting delivery.
Verbatim wording from the response “contact details of services they can contact in a crisis.” Source location Response from Priory Group
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Concerns raised 1
Failure to maintain a signed record of patient self-discharge View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Megan Ceris 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
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
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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 maintain a signed record of patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Source location Megan Ceris Williams · 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 Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.
Verbatim wording from the response “In addition, the Trust has updated the Hospital Discharge and Criteria to Reside Policy. The Policy was updated and issued to all staff at the Trust on 16 February 2023. The updated policy directs staff to always consider the following when a patient indicates that they want to self-discharge:” Source location Response from East Kent 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 Require post-discharge welfare telephone calls for ward patients who self-discharge.
Verbatim wording from the response “Of key importance is that patients are asked to review the Self Discharge Form which must then be filed within the patient’s case notes. The Self Discharge Form sets out the risks of discharging against medical advice and asks a patient to consider these risks before signing the form. This is to ensure that patients have weighed the risks of self-discharge and ensures that there is a recorded process. The Policy also mandates that following discharge, if on a ward, then a welfare check telephone call be made to ensure the patient has arrived home safely.” Source location Response from East Kent Hospitals
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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 No actions by NICE are considered necessary to address the issues raised in the report.
Verbatim wording from the response “On this occasion, we do not consider that there are any actions from NICE that would address the issues raised.” Source location Response from NICE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns are local Trust issues outside NHS England’s remit.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” Source location Response from NHS England
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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 East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” Source location Response from NHS England
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17 May 2024 Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 1
Failure of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors 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
Jonathan Paul SZCZEPANSKI · 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
Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.
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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 hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors
Wider context from the report “(3) Where repeat prescriptions were issued on discharge of a patient from hospital back
to community primary care, there was no warning on the discharge documentation
to alert the prescriber to the considerations and risk factors in the prescription of
NSAIDs (including the use of PPI).
” Source location Jonathan Paul SZCZEPANSKI · 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 Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
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14 May 2024 Carol Ann DIVALL · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Failure to provide accurate and complete discharge information View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carol Ann DIVALL · 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
Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.
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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 provide accurate and complete discharge information
Wider context from the report “D. The Discharge Summary was misleading to the District Nurses who were unaware of the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did not make clear that Mrs Divall had been discharged for end of life care .
” Source location Carol Ann DIVALL · 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 Develop and implement the 5P discharge process for communicating significant pressure damage.
Verbatim wording from the response “The Chief Nurse has proposed a new process called the ‘5P Process for Discharge’ to improve the communication related to significant pressure damage on discharge. This has been presented and discussed at length with senior nurses across the organisation and is currently being developed and implemented. The process includes utilising our medical illustration team to take clear images of wounds for sharing with carers with consent as required. We have included a copy of the process as Attachment A, and a copy of the 5P slide deck at Attachment B.” Source location Response from East Sussex Healthcare
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Verbatim wording from the response “To address these information concerns, we have developed a flow chart on how to refer to District Nurses and what information needs to be shared to support decision making and tasks related to fast track discharge, available on the extranet and in the discharge policy.” Source location Response from East Sussex Healthcare
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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 Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
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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 Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
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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 Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
Verbatim wording from the response “By applying this approach to the care delivered to Mrs Divall the Trust acknowledge and accept the concerns of the Coroner. We are aware we need to review and improve our communication with next of kin and, as above, between teams on discharge such as the District Nurses and ward to ensure important information is cascaded avoiding confusion and distress to families. We now have bimonthly Quality Summits which all the Ward Matrons will be attending in person to emphasise the importance of communication between families but also between staff in order to ensure that care provided is of the highest quality. We have also developed quality documentation audits and discharge checklist audits so that where we see a miscommunication we can put it right in the moment.” Source location Response from East Sussex Healthcare
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Concerns raised 1
Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty View source
This report raised 10 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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Sally Poynton · 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
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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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 Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Source location Sally Poynton · Prevention of Future Deaths report
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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 Integrated Care Board is expected to respond to concerns about the specific care provided.
Verbatim wording from the response “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.” Source location 2024-0267 Response from Department of Health and Social Care
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Includes failures to create, complete, retain or make available hospital discharge documentation, including the reason for discharge, discharge decisions, follow-up or advice, and other material information needed for continuity and safe review.
