Recurring concern

Unreliable healthcare patient transfer processes

First to latest report 17 Sep 2013 — 24 Jun 2026

Reports that mention this concern
103
Times this concern has been raised
131
Stated actions linked to this concern
151

What this concern includes

Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.

What is not included
  • Ordinary shift handover with no transfer of the patient or care responsibility
  • Clinical treatment failures after a safe and complete transfer
  • Discharge to the community where no healthcare transfer process is involved

Reports and published responses 103 reports

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

  1. Derby and Derbyshire

    AI-generated summary

    Kenneth 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

    Kenneth Perkins, who had a history of recurrent falls and several co-morbidities, was admitted to Royal Derby Hospital after presenting with left-sided weakness, facial droop and confusion. While confused and lacking capacity, he wandered without assistance despite a risk assessment requiring one carer when mobilising, fell and hit his head, and later died on 11 September 2018 after subarachnoid bleeding could not be treated. The principal concern was the absence of a clear, detailed transfer handover covering his medication, medical history and recurrent falls, and the receiving hospital’s failure to request one, which may have prevented enhanced care and observation being put in place.

    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 clear, detailed transfer documentation covering medication, medical history and recurrent falls

    Wider context from the report

    “Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document. That history would have allowed an enhanced level of care and observation to be put in place so as to prevent further falls. ”

    Source location

    Kenneth PERKINS · Prevention of Future Deaths report
    Page 1 · concerns

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to request a transfer document

    Wider context from the report

    “Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document. That history would have allowed an enhanced level of care and observation to be put in place so as to prevent further falls. ”

    Source location

    Kenneth PERKINS · 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

    Use standardized SBAR transfer documentation to communicate patients’ clinical history, needs and risks between care providers.

    Verbatim wording from the response

    “In line with the evidence already submitted to the Court, DCHS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for DCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins.”

    Source location

    Response from University Hospital of Derby and Burton
    Page 2 · response
    Published 20 October 2022

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    DCHS considers its established Admission, Discharge and Transfer Policy and SBAR process sufficient for safe patient transfers.

    Verbatim wording from the response

    “In line with the evidence already submitted to the Court, DCHS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for DCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins.”

    Source location

    Response from University Hospital of Derby and Burton
    Page 2 · response
    Published 20 October 2022

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    UHDB considers established transfer, admission-assessment and information-sharing processes sufficient to support safe information exchange between care providers.

    Verbatim wording from the response

    “The information from the transferring care provider is taken into consideration by the Trust, but it is not decisive. On admission to the Trust staff should complete further assessments to assess the patient's abilities and needs at that specific time, including mental capacity and falls risk assessment.”

    Source location

    Response from University Hospital of Derby and Burton
    Page 2 · response
    Published 20 October 2022

    Open published response

  2. Manchester South

    AI-generated summary

    Kenneth Goodwin · 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 Goodwin was admitted to hospital with severe abdominal pain and was being treated for sepsis from gall stones and cholecystitis. After being transferred between wards at night, he fell before a falls risk assessment had been completed on the new ward, developed an acute subdural haematoma, and died on 9 June 2022. Concerns included the lack of required written confirmation of falls-risk handover, the delay in completing the new ward’s falls risk assessment, and inconsistent use of visual falls-risk signs on beds.

    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 specific written confirmation of falls-risk handovers between wards

    Wider context from the report

    “(1) The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place. ”

    Source location

    Kenneth Goodwin · 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

    Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.

    Verbatim wording from the response

    “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remove all unauthorised patient handover documents from use.

    Verbatim wording from the response

    “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.

    Verbatim wording from the response

    “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.

    Verbatim wording from the response

    “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.

    Verbatim wording from the response

    “The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.

    Verbatim wording from the response

    “The Trust can confirm that there is a six hour standard for risk assessments to be completed following transfer of a patient to a ward. This window allows the receiving team to admit the patient into their care, undertake”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 1 · response
    Published 14 October 2022

    Open published response

  3. West Sussex

    AI-generated summary

    Stephen WELLS · 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

    Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.

    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

    Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT

    Wider context from the report

    “c) I heard evidence that Mr Wells was told his key contact in SASH was a named Clinical Nurse Specialist. When his care transferred to RSFT, witnesses expected his key contact to be changed to a CNS based within the St Luke’s Cancer Centre in Guildford. During the inquest I asked to whom the CNS was at RSFT and following enquiries learnt that the St Luke’s staff believed the key contact was the SASH CNS. I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa. ”

    Source location

    Stephen WELLS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement an inter-organisation transfer pathway that gives patients, GPs and receiving clinicians the receiving organisation’s nominated contact details.

    Verbatim wording from the response

    “Following the concerns identified during the inquest the Trusts have been working on an agreed pathway that will ensure that patients themselves receive a letter at the point when their care is due to be transferred to another organisation. This letter will contain the key contact details including a telephone number for the nominated point of contact at the receiving organisation. The patient will therefore always have the key contact details available to them. The letter will also be copied to the patients GP and to the receiving clinical nurse specialist at the receiving hospital. This ensures that the GP has access to the contact details of the nominated point of contact should they need to raise any concerns or otherwise make contact with the treating clinical team.”

    Source location

    Response from Royal Surrey Foundation Trust NHS
    Page 3 · response
    Published 4 October 2022

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ratify and use a proforma transfer letter, providing it to patients at their final face-to-face visit and copying it to their GP and receiving Clinical Nurse Specialist.

    Verbatim wording from the response

    “RSFT have developed a proforma letter to use at the point when a patient’s care is due to be transferred to another organisation. This letter is due to be ratified by the RSFT Oncology department on the 4th November and will then be used for all patients where care is being transferred from RSFT to our referring hospitals. Patients will receive this letter in person at their final face to face visit, this will avoid any issues with the letter being lost or delayed in a postal process and ensure that the patient is clear on how and who to contact should they have concerns following their transfer of care. The letter will then be copied to the patient’s GP and to the Clinical Nurse Specialist at the receiving Trust who will taking on the role of the nominated point of contact for that patient.”

    Source location

    Response from Royal Surrey Foundation Trust NHS
    Page 4 · response
    Published 4 October 2022

    Open published response

  4. Bedfordshire and Luton

    AI-generated summary

    Yuksel Bedri ISMAIL · 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

    Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

    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 consult PLS staff about escort and transfer arrangements

    Wider context from the report

    “1. The Court was told that SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made. Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue: - Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements. ”

    Source location

    Yuksel Bedri ISMAIL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. South Yorkshire (Western)

    AI-generated summary

    Ann Pickering · 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

    Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.

    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 clear procedures for transferring patients under a section

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

    Source location

    Ann Pickering · 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

    Lack of clear procedures for documentation and resources accompanying transferred patients

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

    Source location

    Ann Pickering · 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

    Delays in accepting transfers of patients under a section

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

    Source location

    Ann Pickering · 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

    Distribute interim transfer guidance to staff of both Trusts.

    Verbatim wording from the response

    “An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities – for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1).”

    Source location

    Response from NHS South West Yorkshire Partnership
    Page 2 · response
    Published 27 September 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.

    Verbatim wording from the response

    “An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities – for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1).”

    Source location

    Response from NHS South West Yorkshire Partnership
    Page 2 · response
    Published 27 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.

    Verbatim wording from the response

    “BHNFT and SWYPFT are improving and clarifying the process which includes a protocol that details operational delivery of a safe and effective pathway, which will include:”

    Source location

    Response from NHS South West Yorkshire Partnership
    Page 1 · response
    Published 27 September 2022

    Open published response

  6. West Yorkshire Eastern

    AI-generated summary

    Alexander George Theodossiadis · 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

    Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.

    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 a nurse escort during transfer of severely unwell and confused patients

    Wider context from the report

    “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance. ”

    Source location

    Alexander George Theodossiadis · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Cross-city nurse escorts are sometimes impracticable because they remove experienced staff for over an hour and may compromise care of other patients.

    Verbatim wording from the response

    “Given the large volumes of patients within both Emergency Departments across the city, it is sometimes not possible or practicable for a nurse to personally escort patients for a cross-city transfer. To do so would deplete the department of an experienced nurse for over an hour, with the potential to compromise care of other patients waiting for treatment. Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who will facilitate safe transfer. For transfers within the same hospital, a now improving staff position means that, wherever possible, the patient will be accompanied to the new ward or clinical area by a member of the ED staff so that a direct handover can be facilitated.”

    Source location

    2021-0412-Response-from-St-Jamess-University-Hospital_Published
    Page 2 · response
    Published 10 December 2021

    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

    Yorkshire Ambulance Service facilitates safe transfer for cross-city patients instead of a Trust nurse escort.

    Verbatim wording from the response

    “Given the large volumes of patients within both Emergency Departments across the city, it is sometimes not possible or practicable for a nurse to personally escort patients for a cross-city transfer. To do so would deplete the department of an experienced nurse for over an hour, with the potential to compromise care of other patients waiting for treatment. Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who will facilitate safe transfer. For transfers within the same hospital, a now improving staff position means that, wherever possible, the patient will be accompanied to the new ward or clinical area by a member of the ED staff so that a direct handover can be facilitated.”

    Source location

    2021-0412-Response-from-St-Jamess-University-Hospital_Published
    Page 2 · response
    Published 10 December 2021

    Open published response

  7. Manchester City

    AI-generated summary

    Jude Daryl Lloyd · 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

    Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

    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

    Inadequate and incomplete transfer and communication from inpatient care to the CMHT

    Wider context from the report

    “c. The transfer and communication process from inpatient care to the CMHT was inadequate and incomplete. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Address coordination of diabetes management at discharge through the diabetes steering group.

    Verbatim wording from the response

    “The HbA1c is a measurement of control of blood glucose (glycaemic control) over the weeks prior to the test being taken so the HbA1c of 135 suggested extremely poor glycaemic control in the community whilst Mr Lloyd was under the care of his GP prior to admission. We agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to any improvement in glycaemic control and was not a robust plan to manage this. We will address discharge diabetes management coordination via the diabetes steering group.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    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

    Existing discharge CPA requirements in the CMHT procedure and clinical-record audits are relied upon to address discharge planning compliance.

    Verbatim wording from the response

    “The Trust’s investigation report detailed that Mr Lloyd’s Care Coordinator attended the discharge Care Programme Approach (CPA) meeting and participated in agreeing the discharge plan but did not complete a discharge CPA plan in line with Trust expectations when a patient is discharged from hospital. These expectations are already covered in the Trust CMHT Standard Operating Procedure and are monitored through audit of clinical records during management supervision of staff.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    Open published response

  8. Manchester City

    AI-generated summary

    Antony Declan Schofield · 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

    Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

    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

    Inadequate transfer and communication from inpatient care to the HBTT

    Wider context from the report

    “1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”

    Source location

    Antony Declan Schofield · 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

    Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.

    Verbatim wording from the response

    “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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

    HBTT staff reviewed the patient before discharge and considered that the information needed to support transfer had been shared verbally.

    Verbatim wording from the response

    “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    Open published response

  9. Newcastle Upon Tyne and North Tyneside

    AI-generated summary

    Benjamin Clark · 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

    Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.

    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 document justified falls-risk reassessments during hospital transfer

    Wider context from the report

    “1. I heard evidence from Matron ████████ who carried out a Root Cause Analysis following Mr. Clark’s fall in hospital. She told me that despite Mr. Clark having been assessed to be a Level 3 Risk of Falls in Northumbria Specialist Emergency Care Hospital (NSECH), when he was transferred to North Tyneside General Hospital his falls risk was downgraded to Level 2 without any notes being provided to justify this reassessment. ”

    Source location

    Benjamin Clark · 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

    Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

    Verbatim wording from the response

    “4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.”

    Source location

    2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 9 July 2021

    Open published response

  10. East London

    AI-generated summary

    Juliet Saunders · 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

    Juliet Saunders, a 25-year-old woman with Cornelia De Lange Syndrome and a profound learning disability, attended hospital on 7 March 2020 with abdominal pain and vomiting and died at home the following day. The report identified concerns including misinterpretation of abdominal x-rays, failure to diagnose intestinal obstruction, inadequate escalation and supervision, departures from transfer and discharge procedures, lack of safety-netting advice, and insufficient support for patients with learning disabilities at weekends.

    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

    Departure from established procedures for safe transfers from the emergency department to the observation unit

    Wider context from the report

    “6. A departure from established procedures to ensure the safety of transfers out of the emergency department to the observation unit. ”

    Source location

    Juliet Saunders · 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

    Run a weekly task-and-finish group and audits to improve discharge and transfer documentation compliance across both sites.

    Verbatim wording from the response

    “• A weekly task and finish group was set up which was set up led and chaired by the DDON with all Lead Nurses and Matrons attending. Part of its remit was to review our compliance on both sites. Part of its remit has been to review our discharge and transfer compliance on both sites; the Matrons have completed their own weekly audits. We were keen to improve our compliance and tackle our underlying issues and deliver sustained care to our patients.”

    Source location

    2021-0157-Response-from-Queens-Hospital_Published
    Page 3 · response
    Published 18 May 2021

    Open published response

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

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Data last updated 7 September 2026