Recurring concern

Unreliable hospital discharge documentation

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First reported 30 Jan 2013•Latest report 27 May 2026

Definition

What this concern includes

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.

Not included

Excludes failures in the clinical suitability or timing of discharge where discharge documentation is not itself deficient.
Excludes medication-supply, discharge-summary-to-GP and patient-accessibility failures where the specific unsafe condition is a separate named discharge-information process.
Excludes failures to implement post-discharge care after complete and available discharge documentation has been provided.
Excludes generic clinical-record deficiencies unrelated to documenting or retaining hospital discharge information.

Reports: 43
Individual concerns: 47
Date range: 2013–2026
Stated actions: 74

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6

NHS England4

University College London Hospitals NHS Foundation Trust3

Barts Health NHS Trust2

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

Greater Manchester Mental Health NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

University Hospitals Sussex NHS Foundation Trust2

Betsi Cadwaladr University LHB1

Bolton NHS Foundation Trust1

Brunswick Ward at Lindridge1

Central and North West London NHS Foundation Trust1

Central London Community Healthcare NHS Trust1

Cornwall Council1

Concerns and responses across reports

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

5 Feb2024
Essex
Concerns raised1
1. Failure to record agreed family medication-management mitigations in the discharge care plan
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.
Actions described in response 1
1. Action
  Share discharge plans with involved professionals and consented families or carers, and prompt staff to check agreed medication plans.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Georgia Dehaney-Perkins · 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

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record agreed family medication-management mitigations in the discharge care plan
Wider context from the report
“(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
Source location
Georgia Dehaney-Perkins · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share discharge plans with involved professionals and consented families or carers, and prompt staff to check agreed medication plans.

Verbatim wording from the response
“In order to strengthen safety measures in relation to this concern the wards now have in place that post each discharge meeting, discharge plans are shared with all health professionals and family/carers (with consent) involved in the care of the patient. A prompt is now written in the diary to remind staff to check the discharge plan that has been agreed for that patient including medication plans.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 14 February 2024
Open published response
2 Feb2024
North Wales (East and Central)
Concerns raised1
1. Delays and failures in transferring and acting on discharge clinical documentation
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.
Actions described in response 2
1. Action
  Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
2. Action
  Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
Respondent positions 2
1. Position
  Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
  Stated by Elysium Healthcare LimitedUnable to act
1. Position
  The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
  Stated by Elysium Healthcare LimitedExisting arrangements considered sufficient
AI-generated summary

Philip David Taylor · 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

Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays and failures in transferring and acting on discharge clinical documentation
Wider context from the report
“c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged. d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon. In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor, even where there was a change in medication dosage. ”
Source location
Philip David Taylor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.

Verbatim wording from the response
“The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.

Verbatim wording from the response
“A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.

Verbatim wording from the response
“2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.”

Source location
Response from Elysium Healthcare
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.

Verbatim wording from the response
“The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.”

Source location
Response from Elysium Healthcare
Page 3 · response
Published 12 February 2024
Open published response
19 Jan2024
West London
Concerns raised1
1. Failure to dispatch liaison psychiatry discharge letters promptly
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.
Actions described in response 3
1. Action
  Implement automated templates and secure-email processes for timely mental-health correspondence to general practitioners.
  Stated by West London NHS TrustStated completed
2. Action
  Monitor GP correspondence through daily senior-management checks and governance meetings.
  Stated by West London NHS TrustStated completed
3. Action
  Develop a service-wide tri-borough protocol for GP letters.
  Stated by West London NHS TrustStated in progress
AI-generated summary

Tom Sweeting · 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

Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to dispatch liaison psychiatry discharge letters promptly
Wider context from the report
“2. No letter of discharge was sent at the time Tom was seen by the liaison psychiatry team, and a letter was only generated in response to investigations taking place after the death. The team acknowledged that there were “problems” with sending out letters at the time, and no evidence was brought before the court that this issue has now been resolved. Letters should be dispatched within 24 hours of attendance. Communication between the various community teams and setting out the treatment plan to the patient are important factors that were not effective during Tom’s care and remain a concerning omission where there may be a simple and effective remedy. ”
Source location
Tom Sweeting · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement automated templates and secure-email processes for timely mental-health correspondence to general practitioners.

Verbatim wording from the response
“An automated letter template has been developed, which auto-populates with information pulled from the electronic record, to simplify clinicians’ work when completing these letters. A more robust GP communication process was implemented to send letters to GP practices via secure emails, to eliminate postal delays, with other copies sent by post.”

Source location
Response from West London NHS Trust
Page 3 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor GP correspondence through daily senior-management checks and governance meetings.

Verbatim wording from the response
“This project significantly improved the problem of timely GP correspondence, however the risk of recurrence is not entirely eliminated. Therefore, in light of this Coroner inquest the service is initiating a 3-pronged response to fully address on-going systemic obstacles to timely communication with primary care. GP correspondence is now monitored by the senior management team on a daily basis, is a standing item in the team governance meeting and monitored in the service-wide governance meeting. This will constitute the basis of a new service-wide tri-borough protocol for GP letters, which the LPS service and Clinical Lead are jointly developing as part of our response to this inquest. Since the implementation of the protocol, HLP has achieved 97.1% of letters sent within one working day between 20/02/2024 and 05/03/2024.”

Source location
Response from West London NHS Trust
Page 3 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a service-wide tri-borough protocol for GP letters.

Verbatim wording from the response
“This project significantly improved the problem of timely GP correspondence, however the risk of recurrence is not entirely eliminated. Therefore, in light of this Coroner inquest the service is initiating a 3-pronged response to fully address on-going systemic obstacles to timely communication with primary care. GP correspondence is now monitored by the senior management team on a daily basis, is a standing item in the team governance meeting and monitored in the service-wide governance meeting. This will constitute the basis of a new service-wide tri-borough protocol for GP letters, which the LPS service and Clinical Lead are jointly developing as part of our response to this inquest. Since the implementation of the protocol, HLP has achieved 97.1% of letters sent within one working day between 20/02/2024 and 05/03/2024.”

Source location
Response from West London NHS Trust
Page 3 · response
Published 19 January 2024
Open published response
16 Oct2023
East London
Concerns raised1
1. Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Claire Twinn · 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

Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy
Wider context from the report
“2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record. ”
Source location
Claire Twinn · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Jul2023
North Yorkshire and York
Concerns raised1
1. Lack of discharge notes
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update and disseminate clinical record-keeping guidance to clinical staff.
  Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
3. Action
  Amend the electronic discharge-note template to include required discharge information and advice.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
1. Action
  Disseminate discharge-advice guidance and train registered nurses in its use.
  Stated by Leeds Teaching Hospitals NHS TrustStated planned
AI-generated summary

Carole MCQUINN · 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

Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of discharge notes
Wider context from the report
“1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not. ”
Source location
Carole MCQUINN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update and disseminate clinical record-keeping guidance to clinical staff.

Verbatim wording from the response
“On review of this matter it became apparent that the Trust’s clinical record-keeping guidance was out of date. This was already on the work plan to be updated and will now be expedited. Once the guidance is finalised it will be shared with all clinical staff.”

Source location
Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.

Verbatim wording from the response
“Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.”

Source location
Response from Leeds Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Amend the electronic discharge-note template to include required discharge information and advice.

Verbatim wording from the response
“Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.”

Source location
Response from Leeds Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Disseminate discharge-advice guidance and train registered nurses in its use.

Verbatim wording from the response
“Following the hearing and in response to your report the CSU has reviewed the steps taken to improve discharging practice and it has drafted Good Practice Guidance for the completion of discharge advice notes by registered nurses (please see attachment 2). Dissemination of this guidance, with training for staff, will be complete by the end of October 2023. Support to embed good practice will also be provided by the CSU quality practitioners and the clinical education team by the end of November 2023. The guidance has already been discussed with the nursing staff at the CSU Perfect Ward meeting (where all matrons and ward sisters meet each month to review all quality indicators and incidents within the CSU) and ward sisters are now sharing it with their staff in each ward area.”

Source location
Response from Leeds Teaching Hospitals NHS Foundation Trust
Page 3 · response
Published 21 July 2023
Open published response
27 Jan2023
East London
Concerns raised1
1. Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
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.
AI-generated summary

Toby Wilbur Barwick · 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

Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
Wider context from the report
“1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome (“SIDS”). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied. ”
Source location
Toby Wilbur Barwick · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Dec2022
Inner North London
Concerns raised1
1. Omission of daily skin-integrity checking instruction from discharge assessment form
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.
Actions described in response 12
1. Action
  Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
  Stated by Central London Community Healthcare NHS TrustStated completed
2. Action
  Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
  Stated by Central London Community Healthcare NHS TrustStated completed
3. Action
  Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
  Stated by Central London Community Healthcare NHS TrustStated completed
1. Action
  Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
2. Action
  Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
  Stated by University College London Hospitals NHS Foundation TrustStated in progress
3. Action
  Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
4. Action
  Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
  Stated by Kapital Care (UK) LimitedStated completed
5. Action
  Review organisational recording and documentation practices.
  Stated by Kapital Care (UK) LimitedStatus unclear
6. Action
  Obtain the relevant discharge notification form before starting hospital-discharge care packages.
  Stated by Kapital Care (UK) LimitedStated planned
7. Action
  Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
  Stated by Westminster City CouncilStated in progress
8. Action
  Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
9. Action
  Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
  Stated by University College London Hospitals NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
  Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Richard Thomas SHANNON · 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

Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report
“4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.

Verbatim wording from the response
“• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.

Verbatim wording from the response
“• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.

Verbatim wording from the response
“• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review organisational recording and documentation practices.

Verbatim wording from the response
“• Review of recording and documentation within the organisation.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Obtain the relevant discharge notification form before starting hospital-discharge care packages.

Verbatim wording from the response
“• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.”

Source location
Response from Kapital Care
Page 3 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.

Verbatim wording from the response
“• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.”

Source location
Response from City of Westminster
Page 2 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient’s notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospital
Page 5 · response
Published 8 December 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.

Verbatim wording from the response
“We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.”

Source location
Response from University College London Hospitals
Page 6 · response
Published 8 December 2022
Open published response
26 Aug2021
Leicester City and South Leicestershire
Concerns raised1
1. Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Cherry Rosemary Dunn · 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

Cherry Rosemary Dunn died after an acute episode at Kirby Ward on 5 November 2018, with the inquest recording pulmonary embolism, deep vein thrombosis and immobility as causes of death. Concerns included bilateral leg swelling not prompting sufficient consideration of deep vein thrombosis, ambiguity in VTE risk assessments, and confusing hospital discharge letters that affected decisions about prophylactic anticoagulation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly
Wider context from the report
“• Hospital discharge letters The discharge letter used when Mrs Dunn was transferred from one hospital setting to another (attached) was confusing. The doctor at the receiving hospital read it to mean that prophylactic anticoagulation was not required and therefore the doctor was persuaded in part by this even though the risk assessment that was completed had a positive result. The University Hospitals of Leicester NHS Trust have now revised their discharge letter (attached) which more clearly reflects NICE Guidance and removes the previous confusion. However, there is a concern that the original discharge letter is used in other Trusts and therefore the confusion remains in other areas with the risk of what happened in this case happening elsewhere. ”
Source location
Cherry Rosemary Dunn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jul2021
Norfolk
Concerns raised2
1. Failure to record pertinent medication history on discharge documentation
2. Failure to provide clear, accurate and complete discharge advice
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remind the Emergency Department team to confirm that patients, relatives and carers understand discharge advice and safety-netting instructions.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated completed
AI-generated summary

Ben Buster KING · 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

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record pertinent medication history on discharge documentation
Wider context from the report
“5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. ”
Source location
Ben Buster KING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide clear, accurate and complete discharge advice
Wider context from the report
“4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate”. On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020. ”
Source location
Ben Buster KING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Remind the Emergency Department team to confirm that patients, relatives and carers understand discharge advice and safety-netting instructions.

Verbatim wording from the response
“• the entire ED team have been reminded to check with carers, relatives and patients that the discharge advice is clear and understood so that people know what to do if the patient’s condition does not improve;”

Source location
2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
Page 3 · response
Published 23 July 2021
Open published response
21 Apr2021
Surrey
Concerns raised1
1. Failure to undertake and record formal pre-discharge risk assessments
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Use the SystmOne risk-assessment node to support structured, evidence-based risk assessments.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
2. Action
  Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
3. Action
  Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
1. Action
  Add weekly audits of discharge checklists to verify completion and close the learning loop.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
2. Action
  Review the Risk Assessment and Management Policy to guide staff in risk assessment and management.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
AI-generated summary

MARY NABILIA GWANYAMA · 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

Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake and record formal pre-discharge risk assessments
Wider context from the report
“3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. ”
Source location
MARY NABILIA GWANYAMA · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the SystmOne risk-assessment node to support structured, evidence-based risk assessments.

Verbatim wording from the response
“In ████████ letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:”

Source location
2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 23 April 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.

Verbatim wording from the response
“In ████████ letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:”

Source location
2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 23 April 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.

Verbatim wording from the response
“In addition to this, in April 2021 we recruited a Lead Nurse for Quality and Practice, specifically for inpatient services. Part of her role is around ensuring the quality of our inpatient care plans and risk assessments and identifying areas for improvement. We have also delivered a significant amount of Suicide Prevention Training across our clinical services.”

Source location
2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 23 April 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Add weekly audits of discharge checklists to verify completion and close the learning loop.

Verbatim wording from the response
“Weekly audits of risk assessments and care plans are conducted by Senior Matrons in ACU and Farnham Road Hospital. We also have in place a discharge checklist, to include whether a risk assessment has been completed prior to discharge. These checklists have been in place for some time; however, they are not routinely audited. We are therefore going to add to the weekly audits a review of the discharge checklist, to ensure they are being completed appropriately and the learning loop closed.”

Source location
2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 23 April 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Risk Assessment and Management Policy to guide staff in risk assessment and management.

Verbatim wording from the response
“We are also reviewing our Risk Assessment and Management Policy to support and guide our staff in how to be confident in risk assessments risk and management.”

Source location
2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 23 April 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record agreed family medication-management mitigations in the discharge care plan

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Delays and failures in transferring and acting on discharge clinical documentation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to dispatch liaison psychiatry discharge letters promptly

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy

Concerns raised1

Lack of discharge notes

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices

Concerns raised1

Omission of daily skin-integrity checking instruction from discharge assessment form

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12

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

Actions described in response 1

Actions described in response 2

Respondent positions 2

Actions described in response 3

Actions described in response 4

Actions described in response 12

Respondent positions 1