Recurring concern

Failure to provide timely and adequate follow-up after discharge

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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

Distinct published reports

Individual concerns
66

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
56

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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. Manchester North

    AI-generated summary

    Anthony Maurice Huggan · 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 Maurice Huggan, who had a longstanding drug problem, was admitted to hospital after an accidental opiate overdose but self-discharged against medical advice on 3 June 2014. He was found deceased at home the following day after taking excessive amounts of prescribed and illicit substances; post-mortem examination and toxicology identified combined drugs toxicity involving Pregabalin, Morphine and Methadone. Concerns included the lack of an out-of-hours community drugs service and the timeliness of follow-up or welfare checks after a life-threatening overdose and self-discharge.

    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 follow-up and welfare checks after self-discharge following a life-threatening drugs overdose

    Wider context from the report

    “2. Where a patient takes self-discharge following a life threatening drugs overdose, concerns arise around the timeliness of follow up/welfare checks, given the limitations of the service commissioned by the Local Authority. ”

    Source location

    Anthony Maurice Huggan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    Janette Insley · 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

    Janette Insley had a longstanding history of depressive illness and was admitted to a mental health unit after her mental and psychological health deteriorated. After failing to return from home leave on 3 August 2014, she was found deceased at home having self-ligatured; concerns included a lack of inpatient psychological therapy provision and delays in accessing community-based therapy after discharge.

    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 community-based psychological therapy referrals after discharge

    Wider context from the report

    “3. That any referral to/consultation with a Psychologist based within the community would have taken at least 3-4 weeks post-discharge, thus leaving the patient without therapy during a particularly vulnerable period. ”

    Source location

    Janette Insley · 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

    Publish a five-year mental health plan setting out actions to improve access and waiting times for mental health services.

    Verbatim wording from the response

    “The Outcomes Framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the IAPT programme. In addition, the Department’s new five-year plan for mental health, Achieving Better Access to Mental Health Services by 2020 was published in October 2014. This articulates our ambition and the immediate actions we will take this year and next to achieve better access and waiting times in mental health services. This includes the IAPT commitment of treatment within 6 weeks for 75% of people with 95% of people being treated within 18 weeks.”

    Source location

    2014-0574-Response-by-Department-of-Health
    Page 2 · response
    Published 14 December 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

    Take immediate actions to improve mental health access and waiting times, including IAPT treatment within six weeks for 75% and within 18 weeks for 95% of people.

    Verbatim wording from the response

    “The Outcomes Framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the IAPT programme. In addition, the Department’s new five-year plan for mental health, Achieving Better Access to Mental Health Services by 2020 was published in October 2014. This articulates our ambition and the immediate actions we will take this year and next to achieve better access and waiting times in mental health services. This includes the IAPT commitment of treatment within 6 weeks for 75% of people with 95% of people being treated within 18 weeks.”

    Source location

    2014-0574-Response-by-Department-of-Health
    Page 2 · response
    Published 14 December 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

    The NHS Trust and Clinical Commissioning Group are responsible for addressing the concerns about local psychological therapy provision.

    Verbatim wording from the response

    “You have copied your report to the relevant NHS Trust and Clinical Commissioning Group. The issues you raised are most appropriately addressed at a local level and I would expect the NHS organisations responsible to respond fully to your concerns.”

    Source location

    2014-0574-Response-by-Department-of-Health
    Page 2 · response
    Published 14 December 2014

    Open published response

  3. Inner South London

    AI-generated summary

    CHRISTOPHER TOKE AJAYI · 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 Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

    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 ensure post-discharge follow-up visits

    Wider context from the report

    “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death. In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day. On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge. Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him. To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society. It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators. I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing. I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again. ”

    Source location

    CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.

    Verbatim wording from the response

    “• The community team involved have undertaken two specific audits: (a) Team 7 day follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of two patients with unstable diabetes (Dec 2014) demonstrated extensive communication and forward planning prior to discharge, appropriately involving all partners.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 4 · response
    Published 31 October 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

    Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.

    Verbatim wording from the response

    “Robust discharge planning and follow up and support to care coordinators are supported by the actions outlined in this report. However, the Trust will undertake an audit in March 2015 to assure itself and partners that implementation has been effective.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 8 · response
    Published 31 October 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

    There are no systemic problems with discharge and community follow-up for patients with complex mental and physical health needs.

    Verbatim wording from the response

    “The Trust acknowledges that important lessons have been learnt from this specific case that are being taken forward in improving integrated working; the Trust is otherwise confident that there is no systemic problems with regard to discharge and community follow up of similar patients with complex mental and physical health problems.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 8 · response
    Published 31 October 2014

    Open published response

  4. County Durham and Darlington

    AI-generated summary

    Linda Hudson · 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

    Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after discharge.

    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

    Delay in scheduling post-discharge nursing follow-up

    Wider context from the report

    “(3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday. The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though she was unable to say whether this might have made any difference in all the circumstances. ”

    Source location

    Linda Hudson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Gareth Mark Slater · 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

    Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

    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 appointments at discharge

    Wider context from the report

    “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of discharge. ”

    Source location

    Gareth Mark Slater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026