Recurring concern

Failure to provide timely and adequate follow-up after discharge

Get email alerts

Request correction

First reported 30 Jan 2013•Latest report 23 Oct 2025

Definition

What this concern includes

Includes failures of the post-discharge process, including absent or delayed follow-up care, appointments, referrals, contact, treatment plans, monitoring, or community support where these are needed after discharge.

Not included

Excludes failures confined to pre-discharge assessment or the discharge decision unless they directly concern arranging continuing post-discharge care.
Excludes missed-appointment follow-up where no discharge or post-discharge care process is involved.
Excludes generic staffing, communication, documentation or community-care deficiencies unless they directly cause or form part of inadequate follow-up after discharge.
Excludes unrelated care transitions that do not concern follow-up after discharge.

Reports: 55
Individual concerns: 66
Date range: 2013–2025
Stated actions: 56

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8

NHS England5

Pennine Care NHS Foundation Trust4

Care Quality Commission3

Midlands Partnership University NHS Foundation Trust3

NHS Greater Manchester Integrated Care Board3

Black Country Healthcare NHS Foundation Trust2

East London NHS Foundation Trust2

Greater Manchester Health and Social Care Partnership2

Leicestershire Partnership NHS Trust2

South London and Maudsley NHS Foundation Trust2

Tameside and Glossop Integrated Care NHS Foundation Trust2

Aneurin Bevan University LHB1

Barts Health NHS Trust1

Betsi Cadwaladr University LHB1

Concerns and responses across reports

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

1 Mar2023
Inner West London
Concerns raised2
1. Failure to arrange follow-up appointments before discharge
2. Failure to contact the patient after discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
  Stated by Priory GroupStated completed
2. Action
  Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
  Stated by Priory GroupStated planned
3. Action
  Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
  Stated by Priory GroupStated in progress
1. Action
  Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.
  Stated by Priory GroupStated completed
2. Action
  Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.
  Stated by Priory GroupStated in progress
AI-generated summary

Annabel Jean Findlay · 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

Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause of death.

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 arrange follow-up appointments before discharge
Wider context from the report
“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
Source location
Annabel Jean Findlay · Prevention of Future Deaths report
Page 2 · 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 contact the patient after discharge
Wider context from the report
“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
Source location
Annabel Jean Findlay · 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
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.

Verbatim wording from the response
“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.

Verbatim wording from the response
“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
Open published response
25 Jan2023
Inner North London
Concerns raised1
1. Delays in neighbourhood team allocation after discharge
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Andrew Mark Largin · 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

Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.

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 in neighbourhood team allocation after discharge
Wider context from the report
“1. The ELFT serious incident (SI) review report identified that, although Mr Largin was discharged to the Woodberry Wetlands neighbourhood rehabilitation team from the crisis (i.e. home treatment) team on 25 January 2022, the neighbourhood team did not allocate him to a team member until 3 February. ”
Source location
Andrew Mark Largin · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Nov2022
Milton Keynes
Concerns raised1
1. Lack of automatic follow-up for patients discharged home who may need support and care
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 4
1. Position
  The patient did not refuse to wait for care; he was assessed as not requiring a care package.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
1. Position
  The hospital identified nothing it would do differently in similar circumstances.
  Stated by Milton Keynes University Hospital NHS Foundation TrustNo action considered necessary
2. Position
  Hospital discharge procedures functioned well and were considered an adequate response in this case.
  Stated by Milton Keynes University Hospital NHS Foundation TrustExisting arrangements considered sufficient
3. Position
  MKUH was responsible for the inpatient discharge process because CNWL received no referral and was not involved in the inpatient care.
  Stated by Central and North West London NHS Foundation TrustRedirects responsibility
AI-generated summary

Ronald Alfred KELLY · 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

Ronald Alfred KELLY, aged 91, was found hanging on 19 September 2022 after recently being discharged from hospital and struggling to cope. The concerns included his discharge following surgery without a care package or follow-up, a rejected district nurse referral that was not actioned, and the apparent absence of a system for automatically following up patients discharged home who may need support and care. The inquest concluded that Mr Kelly died from suicide.

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 automatic follow-up for patients discharged home who may need support and care
Wider context from the report
“1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping. 2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first”. The GP forwarded the referral but nothing was actioned. 3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up. ”
Source location
Ronald Alfred KELLY · Prevention of Future Deaths report
Page 1 · 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
The patient did not refuse to wait for care; he was assessed as not requiring a care package.

Verbatim wording from the response
“Mr Kelly was judged to have mental capacity throughout his admission (from providing informed consent for surgical intervention, through to discharge planning). His self-autonomy was respected in line with his mental capacity. Importantly, Mr Kelly did not ‘refuse to wait over the weekend for a care package’: he was not judged to require a care package, nor did he or his partner seek one.”

Source location
Response from Milton Keynes University Hospital
Page 3 · response
Published 21 November 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 hospital identified nothing it would do differently in similar circumstances.

Verbatim wording from the response
“While it is impossible not to be affected by the circumstances of Mr Kelly’s death over two weeks later, we have not identified anything that we would seek to do differently in similar circumstances. An elderly gentleman received prompt surgical treatment and his discharge needs were subsequently explored with him and his family by”

Source location
Response from Milton Keynes University Hospital
Page 2 · response
Published 21 November 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
Hospital discharge procedures functioned well and were considered an adequate response in this case.

Verbatim wording from the response
“I am conscious that discharge from hospital can be a challenging area, with widespread concern nationally around the availability of domiciliary support and funding of the same. On this occasion, I consider that hospital procedures functioned well and could not reasonably have foreseen subsequent events. It is unfortunate that a Regulation 28 Report was felt to be the appropriate route for us to share this information.”

Source location
Response from Milton Keynes University Hospital
Page 3 · response
Published 21 November 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
MKUH was responsible for the inpatient discharge process because CNWL received no referral and was not involved in the inpatient care.

Verbatim wording from the response
“In response to your first point, we did not receive a referral for Mr Kelly either before or at the point of discharge and were not involved in his care whilst he was an inpatient at MKUH. We note that MKUH have provided a full response in relation to the discharge process, which they kindly shared with us.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 21 November 2022
Open published response
12 Jul2022
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Lack of a route back into the Mental Health Service after CRHT discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Kieran Joseph Kevan CRIMMINS · 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

Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.

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 a route back into the Mental Health Service after CRHT discharge
Wider context from the report
“(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies. My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy. ”
Source location
Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
9 Jun2022
East London
Concerns raised1
1. Delays in re-accessing older age community psychiatry teams after discharge
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.
  Stated by Department of Health and Social CareStated completed
2. Action
  Set clear standards for access to community mental-health treatment.
  Stated by Department of Health and Social CareStated planned
3. Action
  Work with NHS England on next steps following its consultation on proposed community mental-health waiting-time standards.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Shirley Alice Moloney · 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

Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.

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 in re-accessing older age community psychiatry teams after discharge
Wider context from the report
“(iii) Once discharged from an older age community psychiatry team, it can take a very long time to access the teams again. These delays can act as a deterrent to GPs in referring patients to community mental health teams. ”
Source location
Shirley Alice Moloney · 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
Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.

Verbatim wording from the response
“You have raised concerns around the resourcing of older age psychiatric teams. We recognise the need to increase capacity in NHS mental health services, including community mental health services for older adults, due to the increasing demand for services. The mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared with December 2020, and by over 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services for all ages. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 20 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
Set clear standards for access to community mental-health treatment.

Verbatim wording from the response
“We are also committed to setting clear standards for patients requiring access to community mental health treatment. NHS England has consulted on the potential to introduce five new waiting time standards as part of its clinically led review of NHS Access Standards. These include a proposal that adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of that consultation in February, and we are now working with them on the next steps.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 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
Work with NHS England on next steps following its consultation on proposed community mental-health waiting-time standards.

Verbatim wording from the response
“We are also committed to setting clear standards for patients requiring access to community mental health treatment. NHS England has consulted on the potential to introduce five new waiting time standards as part of its clinically led review of NHS Access Standards. These include a proposal that adults and older adults presenting to community-based mental health services should start to receive help within four weeks from referral. NHS England published the outcomes of that consultation in February, and we are now working with them on the next steps.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 September 2022
Open published response
8 Apr2022
Inner West London
Concerns raised1
1. Lack of enhanced monitoring for babies at increased risk of early neonatal collapse after discharge to the postnatal ward
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Manhareen Kaur · 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

Manhareen Kaur, a baby born after a kiwi-assisted delivery, was found collapsed on the postnatal ward and died two days later after resuscitation and transfer to a neonatal unit. The principal concern was that babies at increased risk of early neonatal collapse were not provided enhanced monitoring of breathing, heart rate or oxygen saturations on the postnatal ward, leaving no intermediate monitoring option to support earlier detection and resuscitation.

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 enhanced monitoring for babies at increased risk of early neonatal collapse after discharge to the postnatal ward
Wider context from the report
“That babies at relative increased risk of early neonatal collapse due to deliveries complicated by factors such as assisted delivery, meconium staining, or early resuscitation assistance, are discharged back to the postnatal ward with no enhanced monitoring of their breathing, heart rate or oxygen saturations, unless they require admission to PICU or neonatal wards. In short that there is no “middle ground” which may allow early detection of collapse and thus increased chance of successful resuscitation should collapse occur. ”
Source location
Manhareen Kaur · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Mar2022
Surrey
Concerns raised1
1. Failure to follow and maintain an adequate post-discharge care package
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Melanie Jane ELMS · 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

Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.

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 follow and maintain an adequate post-discharge care package
Wider context from the report
“1. The care package arranged for Melanie following discharge from lengthy in-patient admission was not followed and was altered to something which the treating doctor did not consider adequate. ”
Source location
Melanie Jane ELMS · Prevention of Future Deaths report
Page 7 · concerns
Open source report
23 Aug2021
Manchester South
Concerns raised2
1. Failure to monitor deteriorating health early after discharge into the community
2. Limited post-discharge support for vulnerable patients in the community
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Norma Rushworth · 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

Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication difficulties.

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 monitor deteriorating health early after discharge into the community
Wider context from the report
“2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
Source location
Norma Rushworth · Prevention of Future Deaths report
Page 2 · 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
Limited post-discharge support for vulnerable patients in the community
Wider context from the report
“2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
Source location
Norma Rushworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2020
Lincolnshire
Concerns raised1
1. Lack of assertive outreach and organised welfare checks after community discharge
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.
  Stated by Lincolnshire County CouncilRedirects responsibility
1. Position
  A police welfare check was not considered necessary based on the information available at the time.
  Stated by Lincolnshire Partnership NHS Foundation TrustNo action considered necessary
AI-generated summary

Toby Peter Edward Nieland · 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 Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

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 assertive outreach and organised welfare checks after community discharge
Wider context from the report
“6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care; ”
Source location
Toby Peter Edward Nieland · Prevention of Future Deaths report
Page 4 · 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
Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.

Verbatim wording from the response
“This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.”

Source location
2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Page 3 · response
Published 26 October 2020
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
A police welfare check was not considered necessary based on the information available at the time.

Verbatim wording from the response
“The Trust was informed by the out of area inpatient unit that Mr Nieland had been discharged into the community. In accordance with Trust policy and national guidance, the Trust’s Crisis Resolution and Home Treatment Team offered timely follow-up appointments with Mr Nieland to assess his risk and care arrangements. Based upon the information available at the time, a clinical decision to request a police welfare check was not considered necessary. The Trust appreciate the importance of the views of family and carers has in formulating appropriate care arrangements for patients. With the benefit of hindsight, it is accepted that the knowledge and concerns of Mr Nieland’s family would have better informed assessment of risk. The Trust is continuing to support staff and to emphasise the importance of working and supporting patients to include family and carers in their care.”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 5 · response
Published 26 October 2020
Open published response
13 Dec2019
Manchester South
Concerns raised2
1. Failure to provide regular CMHT contact in the community
2. Failure to escalate or discuss very limited post-discharge contact
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Steven Keith Marsland · 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

Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.

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 regular CMHT contact in the community
Wider context from the report
“3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge. ”
Source location
Steven Keith Marsland · Prevention of Future Deaths report
Page 2 · 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 escalate or discuss very limited post-discharge contact
Wider context from the report
“3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge. ”
Source location
Steven Keith Marsland · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to arrange follow-up appointments before discharge

Failure to contact the patient after discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Delays in neighbourhood team allocation after discharge

Concerns raised1

Lack of automatic follow-up for patients discharged home who may need support and care

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Lack of a route back into the Mental Health Service after CRHT discharge

Concerns raised1

Delays in re-accessing older age community psychiatry teams after discharge

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

Concerns raised1

Lack of enhanced monitoring for babies at increased risk of early neonatal collapse after discharge to the postnatal ward

Concerns raised1

Failure to follow and maintain an adequate post-discharge care package

Concerns raised2

Failure to monitor deteriorating health early after discharge into the community

Limited post-discharge support for vulnerable patients in the community

Concerns raised1

Lack of assertive outreach and organised welfare checks after community discharge

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

Actions described in response 5

Respondent positions 4

Actions described in response 3

Respondent positions 2