Recurring concern

Failure to provide timely and adequate follow-up after discharge

First to latest report 30 Jan 2013 — 23 Oct 2025

Reports that mention this concern
55
Times this concern has been raised
66
Stated actions linked to this concern
56

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.

What is 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 and published responses 55 reports

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

  1. Manchester South

    AI-generated summary

    Thomas Josef Green · 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

    Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD services.

    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 psychiatric follow-up after hospital discharge

    Wider context from the report

    “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. ”

    Source location

    Thomas Josef Green · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Nuala Seddon · 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

    Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.

    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 appropriate monitoring for patients discharged from ITU

    Wider context from the report

    “(2) The lack of both telemetry and direct nursing visualisation raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring. This potentially remains the case even though the Heart Hospital has now transferred to be part of Barts NHS Trust, as the hospital at Westmoreland Street still operates as part of UCLH. ”

    Source location

    Nuala Seddon · 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

    Lack of available telemetry monitoring for patients discharged from ITU

    Wider context from the report

    “(1) I heard evidence from the ward nurse that concerns regarding lack of available telemetry remain a current issue at the Heart Hospital (which is now part of Barts NHS Trust). This raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring. ”

    Source location

    Nuala Seddon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Gwent

    AI-generated summary

    Mrs Georgina Lewis · 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

    Mrs Georgina Lewis was discharged from a psychiatric unit on 23 September 2013, went missing from home on 27 September, and was found dead in woods near her home on 30 September 2013. Concerns included discharge without family consultation, no discharge plan or follow-up support, and delayed notification to her GP.

    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 put discharge plans and follow-up support in place

    Wider context from the report

    “(2) Following the decision no discharge plan or follow up support was put in place. ”

    Source location

    Mrs Georgina Lewis · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Plymouth, Torbay and South Devon

    AI-generated summary

    Roy Gordon Millar · 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

    Roy Gordon Millar attended hospital with slurred speech and facial droop, and scans identified an abnormality requiring follow-up. The repeat scan results were not sent to the correct consultant, and a requested outpatient appointment was not arranged. A brain tumour was identified after he re-presented with a more severe facial droop, but he died on the date planned for biopsy and debulking surgery; the report also describes failures to book follow-up appointments affecting approximately 146 patients.

    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 book follow-up appointments for discharged patients

    Wider context from the report

    “PHNT instigated a Root Cause Analysis following this incident, a copy of which is enclosed. ████████ the author of the Report and the Trust’s Patient Safety Lead, attended the Inquest. During the course of the hearing it emerged that the Ward Administrat or in the Neurology Department had been recently appointed. She had been trained by her predecessor. Neither the previous nor the current Ward Administrator were aware of their responsibility to book follow-up appointments for patients who had been discharged. Their understanding was that appointments would be arranged by Consultants’ secretaries and it seems apparent that a large number of appointments were made in this way. It emerged during the course of the Inquest that the Ward Administrators in the Neurology Department had not booked follow-up appointments for approximately 26 months. As you will see from the enclosed Root Cause Analysis, PHNT has reviewed 1000 patient admissions and it has revealed that 146 patients die not have follow-up appointments booked. In Mr Millar’s case the evidence I heard was that the follow-up scan being conducted in June 2015 was likely to have led to a biopsy which would have diagnosed the brain tumour. If Mr Millar had undergone earlier surgery, the Inquest heard that he would have had a 50% chance of surviving for a year. ”

    Source location

    Roy Gordon Millar · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. North Wales (East and Central)

    AI-generated summary

    Christopher Glyn Jones · 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 Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.

    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 completion of Care Treatment Plans after inpatient discharge

    Wider context from the report

    “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months. ”

    Source location

    Christopher Glyn Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Exeter and Greater Devon

    AI-generated summary

    Louise Turner · 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

    Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.

    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 adequate post-discharge mental health care and contact

    Wider context from the report

    “(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged. There was inadequate contact and no explanation at Inquest as to why this had not taken place. ”

    Source location

    Louise Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Rutland and North Leicestershire

    AI-generated summary

    Anthony John Preston · 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

    Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

    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 support for high-risk patients and their main carers after discharge

    Wider context from the report

    “(4) As a result, Mr Preston and his main carer ████████ were left without support at a time when he was at high risk. ”

    Source location

    Anthony John Preston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Worcestershire

    AI-generated summary

    Jonathan James LANDER · 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

    Jonathan James Lander was killed on 28 April 2015 when he was struck by a train on tracks near Blackbridge, Worcester Road, Hartlebury. The principal concern was the absence of a policy or procedure for following up individuals seen by one service and then discharged to another service, and that the identified action plan had not been implemented.

    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 follow-up procedures for individuals discharged from one service to another

    Wider context from the report

    “(1) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service. In the course of the inquest I was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015. I was told in the course of the inquest that that policy/procedure has not been implemented. I was left with the sense that this is still to be considered but there appears to be no sense of urgency. I was further told that the Trust has a governance procedure to ensure that action plans are “followed through” but it seems to be clearly the case that this has not worked either. I respectfully suggest that you consider urgently the necessity for such a procedure / policy and to implement it. (2) (3) ”

    Source location

    Jonathan James LANDER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Surrey

    AI-generated summary

    George Nigel Palmer · 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

    George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be made.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of discharge follow-up mechanisms for patients transferring to a different area

    Wider context from the report

    “During the inquest ████████ Registered Mental Health Nurse, provided helpful evidence and the following concerns were highlighted: - • Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. • Appropriateness of follow up letters to the patient in the event of non-contact. I would ask that you consider giving further consideration to the above to ensure that there is no further repetition. ”

    Source location

    George Nigel Palmer · 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

    Review Home Treatment Team processes for sharing information with new providers after service users relocate.

    Verbatim wording from the response

    “Further to the Inquest, we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged from our services due to their relocation to other parts of the country. Staff in the Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team.”

    Source location

    2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
    Page 1 · response
    Published 15 September 2014

    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 Home Treatment Team staff of local discharge and follow-up procedures for relocated service users.

    Verbatim wording from the response

    “Further to the Inquest, we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged from our services due to their relocation to other parts of the country. Staff in the Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team.”

    Source location

    2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
    Page 1 · response
    Published 15 September 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Obtain relocated service users’ residence and GP details, refer them to local mental health services, and notify the original GP where required.

    Verbatim wording from the response

    “As per our local protocol, our staff will ensure that when they are made aware of the eminent relocation of a person who still requires use of mental health services, they will request from the person, information relating to their new location of residence including GP details. This is to enable us to refer to another provider of Mental Health Services local to them. If the person is yet to be registered with a new GP, we will refer to local services in that new location and also inform their original GP of the discharge and any further referrals for completeness. If a person is temporarily registered with a GP in this area, then their original GP is also notified.”

    Source location

    2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
    Page 1 · response
    Published 15 September 2014

    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

    Ensuring relocated patients receive appropriate mental health support is challenging when they have not registered with a GP because services are mainly GP-aligned.

    Verbatim wording from the response

    “We accept that follow-up letters alone are not sufficient as a means of contact or a way to ensure that people are receiving mental health support in new areas of residence. It is at times quite challenging for us to ensure that a person who has relocated to a new area is receiving the right level of Mental Health support if they have not registered with a GP as the majority of teams are GP aligned. We however work to ensure that people are well supported; for example if a patient using our service chooses to visit family/friends in another area for a period of time, then we proactively ask if they would like mental health input whilst visiting another and a referral is made, supplying information such as current medication prescribed, risk assessment and Care plans.”

    Source location

    2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
    Page 2 · response
    Published 15 September 2014

    Open published response

  10. Cumbria

    AI-generated summary

    Alice Anne McMeekin · 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

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    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

    Discharge without timely and adequate follow-up care for a person remaining at risk

    Wider context from the report

    “2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”

    Source location

    Alice Anne McMeekin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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