Recurring concern

Unreliable hospital discharge documentation

First to latest report 30 Jan 2013 — 27 May 2026

Reports that mention this concern: 43
Times this concern has been raised: 47
Stated actions linked to this concern: 74

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 43 reports

See individual reports that have raised this concern, and the actions taken in response

3 Feb2021
Mid Kent and Medway
Concerns raised1
1. Incomplete and inaccurate discharge nursing documentation
This report raised 12 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

CHRISTOPHER SMITH · Prevention of Future Deaths report

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

Report summary

Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.

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
Incomplete and inaccurate discharge nursing documentation
Wider context from the report
“(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith a. had capacity to make decisions about his care and treatment b. was being cared for in the community. ”
Source location
CHRISTOPHER SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Jan2020
Manchester West
Concerns raised1
1. Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
This report raised 6 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

Daniel Jeffrey Moran · 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

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

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 keep contemporaneous documentation of self-discharge and detention decision-making rationale
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 May2019
Worcestershire
Concerns raised2
1. Failure to retain discharge documentation
2. Failure to provide clear discharge follow-up advice and guidance
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kevin John McDonald · 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

Kevin John McDonald was admitted to hospital after a spinal injury, was assessed and discharged with analgesia, apparently without follow-up. He later died by suicide, leaving a note indicating that he could no longer tolerate the pain. Concerns included unclear discharge advice and follow-up arrangements, with the family stating that he was left unsure what to do about his increasing pain and that no relevant hospital documentation had been found.

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 retain discharge documentation
Wider context from the report
“(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this. ”
Source location
Kevin John McDonald · Prevention of Future Deaths report
Page 1 · 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 discharge follow-up advice and guidance
Wider context from the report
“(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this. ”
Source location
Kevin John McDonald · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 Apr2019
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to transfer complete discharge documentation to the community hospital
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

Terence Douglas Thornton · 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

Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

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 transfer complete discharge documentation to the community hospital
Wider context from the report
“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”
Source location
Terence Douglas Thornton · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Feb2019
Nottinghamshire
Concerns raised1
1. Failure to provide an adequate discharge summary
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions 3
1. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.
2. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.
3. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Continue developing an electronic CDU discharge summary and put it in place within three months.
AI-generated summary

Kathleen McGeary · 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

Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.

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 an adequate discharge summary
Wider context from the report
“3. The electronic discharge summary was inadequate and no paper discharge summary was produced. No explanation was given for this omission. ”
Source location
Kathleen McGeary · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.

Verbatim wording from the response
“I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.”

Source location
2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 5 · response
Published 9 June 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.

Verbatim wording from the response
“I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.”

Source location
2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 5 · response
Published 9 June 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue developing an electronic CDU discharge summary and put it in place within three months.

Verbatim wording from the response
“The Division will continue work on an electronic CDU discharge summary to further enhance the discharge process and aims to have this in place within the next 3 months.”

Source location
2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 6 · response
Published 9 June 2019
Open published response
14 Feb2019
Brighton and Hove
Concerns raised1
1. Incomplete discharge documentation for handover to doctors
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals Sussex NHS Foundation Trust
Stated actions 3
1. University Hospitals Sussex NHS Foundation Trust
  Appoint a discharge facilitator and refocus a band 7 nursing role on admissions, discharges and complete discharge-planning documentation.
2. University Hospitals Sussex NHS Foundation Trust
  Revise the discharge-planner template to clarify recording of key information.
3. University Hospitals Sussex NHS Foundation Trust
  Use documentation audits to review discharge-documentation quality.
AI-generated summary

Kenneth George Alfred WHITTINGTON · 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

Kenneth George Alfred Whittington died following an operation, but the supplied text does not provide further circumstances of his death beyond referring to the Record of Inquest. The principal concerns included inadequate instructions and handover about management of his urinary catheter after bladder repair, failure to check a disconnected epidural despite increasing pain, incomplete blood transfusion and discharge documentation, and a delay to the initial operation because no Junior Doctor was present.

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
Incomplete discharge documentation for handover to doctors
Wider context from the report
“(6) Mr. Whittington was due to be discharged on the 4th May. His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable. ”
Source location
Kenneth George Alfred WHITTINGTON · 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
Appoint a discharge facilitator and refocus a band 7 nursing role on admissions, discharges and complete discharge-planning documentation.

Verbatim wording from the response
“Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.”

Source location
2019-0049-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Revise the discharge-planner template to clarify recording of key information.

Verbatim wording from the response
“Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.”

Source location
2019-0049-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use documentation audits to review discharge-documentation quality.

Verbatim wording from the response
“Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.”

Source location
2019-0049-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 24 May 2019
Open published response
31 Oct2018
Leicester City and South Leicestershire
Concerns raised1
1. Lack of standard patient discharge information materials
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

Dorothy Joan Strickley · 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

Dorothy Joan Strickley underwent emergency surgery for appendicitis on 10 June 2018 and was discharged without the anti-embolic stockings prescribed to her or information about continuing to wear them and seeking urgent medical attention. She became short of breath at home and died 19 days after surgery from a massive pulmonary embolism; concerns included failures to provide the stockings, communicate their use, and ensure discharge documentation and local policy reflected relevant guidance.

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 standard patient discharge information materials
Wider context from the report
“A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”
Source location
Dorothy Joan Strickley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 May2018
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to include falls in hospital discharge information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals of North Midlands NHS Trust
Stated actions 3
1. University Hospitals of North Midlands NHS Trust
  Require significant inpatient falls to be recorded in discharge summaries.
2. University Hospitals of North Midlands NHS Trust
  Coordinate an audit of discharge summaries with external auditors.
3. University Hospitals of North Midlands NHS Trust
  Address findings from the discharge-summary audit.
AI-generated summary

Kenneth William Horne · 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

Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

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 include falls in hospital discharge information
Wider context from the report
“(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter. (2) There was no nurse to nurse discharge call between the hospitals. (3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital. As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December. ”
Source location
Kenneth William Horne · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require significant inpatient falls to be recorded in discharge summaries.

Verbatim wording from the response
“1. All Clinical Leads to instruct Junior Doctors and Nurse Practitioners that when summarising discharge letters, any significant event such as patient falls while in hospital is reflected on their discharge summary.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Coordinate an audit of discharge summaries with external auditors.

Verbatim wording from the response
“In addition to this, the Corporate Governance Team are in the process of co-ordinating an audit of discharge summaries with our external auditors. It is hoped that this will take place within the 2018/19 financial year and any findings will be addressed by the Corporate Governance Team.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Address findings from the discharge-summary audit.

Verbatim wording from the response
“In addition to this, the Corporate Governance Team are in the process of co-ordinating an audit of discharge summaries with our external auditors. It is hoped that this will take place within the 2018/19 financial year and any findings will be addressed by the Corporate Governance Team.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
19 Jan2018
Manchester West
Concerns raised1
1. Gaps in clinical record keeping hindering treatment coordination and discharge accountability
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Greater Manchester Mental Health NHS Foundation Trust
Stated actions 5
1. Greater Manchester Mental Health NHS Foundation Trust
  Establish strategic patient-flow leadership and review admission and discharge procedures.
2. Greater Manchester Mental Health NHS Foundation Trust
  Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
3. Greater Manchester Mental Health NHS Foundation Trust
  Introduce the approved PARIS electronic clinical record system across Manchester services.
1. Greater Manchester Mental Health NHS Foundation Trust
  Deliver rolling record-keeping training for Manchester healthcare professionals incorporating lessons from the death.
2. Greater Manchester Mental Health NHS Foundation Trust
  Include record-keeping standards in ongoing clinical-staff audit supervision.
AI-generated summary

William Myers · 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

William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.

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
Gaps in clinical record keeping hindering treatment coordination and discharge accountability
Wider context from the report
“(5) Gaps in record keeping hindered the coordination of treatment. Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge was made. ”
Source location
William Myers · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish strategic patient-flow leadership and review admission and discharge procedures.

Verbatim wording from the response
“As part of the new organisation (GMMH) we now have a designated Strategic Lead for Patient Flow who has reviewed the Standard Operating Procedure for managing admissions and discharges. This role includes the following key elements:”

Source location
2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 2 · response
Published 14 March 2018
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
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.

Verbatim wording from the response
“The trust is reviewing all care-planning procedures in the light of the lessons learned from this case to ensure that there is continuity of care and a consistent management plan with particular emphasis on high-risk individuals. Discharge procedures have also been reviewed and high-risk patients should not be discharged without a completed formal discharge care plan and risk assessment with consultant oversight. The discharge care plans will include consideration of the risk of disengagement and non-compliance and the response to these.”

Source location
2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 2 · response
Published 14 March 2018
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
Introduce the approved PARIS electronic clinical record system across Manchester services.

Verbatim wording from the response
“GMMH has developed a business case to introduce the PARIS electronic clinical record system bring our Manchester services in line with the wider Trust. This has now been approved by the GMMH Trust Board and will be introduced over the next 12-15 months. This will further enhance accessibility of these assessments to the treating teams.”

Source location
2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 3 · response
Published 14 March 2018
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 rolling record-keeping training for Manchester healthcare professionals incorporating lessons from the death.

Verbatim wording from the response
“GMMH has developed a rolling programme for all healthcare professionals promoting the importance of good record keeping. This training is currently being delivered across our Manchester services and will incorporate the lessons learned raised following Mr Lound’s death.”

Source location
2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 4 · response
Published 14 March 2018
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
Include record-keeping standards in ongoing clinical-staff audit supervision.

Verbatim wording from the response
“The importance of good record keeping will form an active part of the ongoing audit supervision of all clinical staff.”

Source location
2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 4 · response
Published 14 March 2018
Open published response
29 Sep2017
Buckinghamshire
Concerns raised1
1. Failure to maintain accurate records of care, fluid intake, diet, nutrition, hospital discharge arrangements and aftercare instructions
This report raised 1 other concern. 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

Helen Yuk Ying BANNISTER · Prevention of Future Deaths report

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

Report summary

Helen Bannister underwent a procedure to insert a PEG feeding tube on 13 May 2016. After discharge, the PEG loosened, causing a leak into her abdomen and an infection; she died of sepsis at Wexham Park Hospital on 17 May 2016. The report identified concerns about incomplete records of care, fluid intake, diet, nutrition, hospital discharge arrangements and aftercare instructions, which could compromise responses to unfolding events.

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 maintain accurate records of care, fluid intake, diet, nutrition, hospital discharge arrangements and aftercare instructions
Wider context from the report
“There was, understandably, a significant volume of documents and records from Lent Rise used to record the various elements of the care Helen Bannister received whilst at Lent Rise. During the course of the investigation and in evidence at the inquest, whilst there was an indication that procedures, documentation and staff awareness had been under review since the death of Helen Bannister, there remains a significant concern that the keeping of accurate records in respect of all aspects of care, fluid intake, diet and nutrition and the proper recording of hospital discharge arrangements and aftercare instructions needs to be improved. There remains a continuing risk that the ability of care workers, nurses, doctors and hospitals to react properly to unfolding events may be compromised by incomplete records intended to accurately document all actions taken and the relevant timings of those actions in the care of a resident. ”
Source location
Helen Yuk Ying BANNISTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Incomplete and inaccurate discharge nursing documentation

Concerns raised1

Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale

Concerns raised2

Failure to retain discharge documentation

Failure to provide clear discharge follow-up advice and guidance

Concerns raised1

Failure to transfer complete discharge documentation to the community hospital

Concerns raised1

Failure to provide an adequate discharge summary

Linked response

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

Concerns raised1

Incomplete discharge documentation for handover to doctors

Linked response

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

Concerns raised1

Lack of standard patient discharge information materials

Concerns raised1

Failure to include falls in hospital discharge information

Linked response

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

Concerns raised1

Gaps in clinical record keeping hindering treatment coordination and discharge accountability

Linked response

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

Stated actions 3

Stated actions 3

Stated actions 3

Stated actions 5