5 Feb 2024 Georgia Dehaney-Perkins · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to record agreed family medication-management mitigations in the discharge care plan View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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
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
Open published response
Concerns raised 1
Delays and failures in transferring and acting on discharge clinical documentation View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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
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
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
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
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
Open published response
19 Jan 2024 Tom Sweeting · Prevention of Future Deaths report West London
View report summary
Concerns raised 1
Failure to dispatch liaison psychiatry discharge letters promptly View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
West London NHS Trust
Implement automated templates and secure-email processes for timely mental-health correspondence to general practitioners.
View source
West London NHS Trust
Monitor GP correspondence through daily senior-management checks and governance meetings.
View source
West London NHS Trust
Develop a service-wide tri-borough protocol for GP letters.
View source
×
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
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
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
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
Open published response
16 Oct 2023 Claire Twinn · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring 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
Open source report
19 Jul 2023 Carole MCQUINN · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 1
Lack of discharge notes View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leeds Teaching Hospitals NHS Trust York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
York and Scarborough Teaching Hospitals NHS Foundation Trust
Update and disseminate clinical record-keeping guidance to clinical staff.
View source
Leeds Teaching Hospitals NHS Trust
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
View source
Leeds Teaching Hospitals NHS Trust
Amend the electronic discharge-note template to include required discharge information and advice.
View source
Leeds Teaching Hospitals NHS Trust
Disseminate discharge-advice guidance and train registered nurses in its use.
View source See 1 more action
×
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
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
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
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
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
Open published response
27 Jan 2023 Toby Wilbur Barwick · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices View source
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
Open source report
5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Omission of daily skin-integrity checking instruction from discharge assessment form View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central London Community Healthcare NHS Trust Kapital Care (UK) Limited University College London Hospitals NHS Foundation Trust Westminster City Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Central London Community Healthcare NHS Trust
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
View source
Central London Community Healthcare NHS Trust
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
View source
Central London Community Healthcare NHS Trust
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
View source
University College London Hospitals NHS Foundation Trust
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
View source
University College London Hospitals NHS Foundation Trust
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.
View source
University College London Hospitals NHS Foundation Trust
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
View source
Kapital Care (UK) Limited
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
View source
Kapital Care (UK) Limited
Review organisational recording and documentation practices.
View source
Kapital Care (UK) Limited
Obtain the relevant discharge notification form before starting hospital-discharge care packages.
View source
Westminster City Council
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
View source
University College London Hospitals NHS Foundation Trust
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
View source
University College London Hospitals NHS Foundation Trust
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
View source See 9 more actions
×
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Open published response
Concerns raised 1
Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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
Open source report
20 Jul 2021 Ben Buster KING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2
Failure to record pertinent medication history on discharge documentation View source Failure to provide clear, accurate and complete discharge advice View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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
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
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
Open published response
21 Apr 2021 MARY NABILIA GWANYAMA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to undertake and record formal pre-discharge risk assessments View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Surrey and Borders Partnership NHS Foundation Trust
Use the SystmOne risk-assessment node to support structured, evidence-based risk assessments.
View source
Surrey and Borders Partnership NHS Foundation Trust
Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.
View source
Surrey and Borders Partnership NHS Foundation Trust
Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.
View source
Surrey and Borders Partnership NHS Foundation Trust
Add weekly audits of discharge checklists to verify completion and close the learning loop.
View source
Surrey and Borders Partnership NHS Foundation Trust
Review the Risk Assessment and Management Policy to guide staff in risk assessment and management.
View source See 2 more actions
×
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
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
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
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
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
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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.