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. Birmingham and Solihull

    AI-generated summary

    Conall Patrick Gould · 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

    Conall Patrick Gould died at Queen Elizabeth Hospital in Birmingham on 13 February 2017 after behaving erratically and collapsing; the medical cause of death was recorded as ecstasy use. The report raised concerns that arrangements for his community mental health follow-up appointment after discharge were not communicated to him or his parents, and that the absence of a clear protocol or written confirmation created a risk that follow-up opportunities could be missed.

    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 that service users and carers receive follow-up appointment details on discharge

    Wider context from the report

    “1. At the time of discharge from Holywell Hospital on the 30th January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2nd February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence of ████████ Consultant Psychiatrist, who saw Conall and his father on the 30th January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust ████████ had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30th January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4. The evidence of ████████ who conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost. ”

    Source location

    Conall Patrick Gould · 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

    Implement enhanced discharge documentation requiring written follow-up details, contact numbers, and agreed information for patients and carers.

    Verbatim wording from the response

    “The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 day follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge. This protocol also directs that a relative/concerned other, identified by the patient, will also be provided with this written information when consent to do so has been given by the patient.”

    Source location

    Conall-Patrick-Response
    Page 1 · response
    Published 28 September 2017

    Open published response

  2. Black Country

    AI-generated summary

    Melvin James and Anne-Marie James · 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

    Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following 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

    Failure to make formal post-discharge referral or contact with community mental health services and general practitioner

    Wider context from the report

    “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community. ”

    Source location

    Melvin James and Anne-Marie James · Prevention of Future Deaths report
    Page 3 · 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 post-discharge community aftercare

    Wider context from the report

    “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community. ”

    Source location

    Melvin James and Anne-Marie James · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Manchester West

    AI-generated summary

    Terence Ryan · Prevention of Future Deaths report

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

    Report summary

    Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.

    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 notify relevant support services and contacts after patient self-discharge

    Wider context from the report

    “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. ”

    Source location

    Terence Ryan · 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

    Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.

    Verbatim wording from the response

    “I have been informed that a bulletin with the key requirements of the Policy for Self-Discharge Against Medical Advice has been prepared for both clinicians and for the nursing staff to heighten awareness of the policy and ensure compliance. This information has been and will be shared/communicated in the following ways:”

    Source location

    2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 3 · response
    Published 6 October 2017

    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 electronic hospital information system to provide ward managers with daily lists of missing discharge summaries and promptly rectify failures or delays in sending them to GPs.

    Verbatim wording from the response

    “As you will be aware the Trust has now implemented a Hospital Information System (HIS) which is an electronic patient records system. Discharge letters are generated electronically through this system. I have been informed that as part of the audit of this system, the Ward Manager will receive a daily list of the patients for whom a discharge summary has not been completed. This is a real time audit so action can be taken to rectify this issue immediately and a discharge summary can be sent to the patient’s GP as the patient is being discharged/shortly after their discharge from the hospital.”

    Source location

    2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 4 · response
    Published 6 October 2017

    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

    Assign self-discharge codes and conduct monthly audits to verify that discharge letters are sent to patients’ GPs, urgently rectifying omissions.

    Verbatim wording from the response

    “In addition, I believe that the Trust’s medical coders, who attach a code to each patient to help categorise patients to enable data to be collated, now assign a code to any patient who has self-discharged. At the end of each month an audit is conducted of the patients with a self-discharge code to check that a discharge letter has been sent to each patient’s GP. For any patients without a discharge letter, the Division is notified and a letter is sent to the patient’s GP urgently.”

    Source location

    2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 4 · response
    Published 6 October 2017

    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 more sophisticated audit of hospital information system records to assess information quality and identify discharge-summary failures or delays in real time.

    Verbatim wording from the response

    “The HIS system is audited and work is currently being undertaken to develop a more sophisticated audit system to assess the quality of the information recorded on HIS. As such the Trust is continually seeking to improve its systems to ensure the best care possible for its patients.”

    Source location

    2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 5 · response
    Published 6 October 2017

    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 existing self-discharge policy and electronic discharge system require GP discharge letters for all patients, addressing discharge communication.

    Verbatim wording from the response

    “Please can I assure you that the Trust does have a Policy for “Self-discharge Against Medical Advice”. I enclose a copy of this policy for your information. This version of the Policy was approved in November 2014 and was in place at the time that Mr Ryan was treated at the Trust.”

    Source location

    2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
    Page 2 · response
    Published 6 October 2017

    Open published response

  4. Inner North London

    AI-generated summary

    Jonathan Anthony MEANEY · 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 Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was 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

    Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care

    Wider context from the report

    “5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful. Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral. He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request. ”

    Source location

    Jonathan Anthony MEANEY · 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

    Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

    Verbatim wording from the response

    “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    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

    CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

    Verbatim wording from the response

    “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    Open published response

  5. Inner North London

    AI-generated summary

    Songul BOZDAG · 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

    Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.

    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 mandatory post-discharge reviews

    Wider context from the report

    “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016. 2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory. 3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error. 4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system. 5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis. These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life. ”

    Source location

    Songul BOZDAG · 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

    Implement a central referrals inbox for communicating hospital discharge plans to CMHT staff, with daily administrative review and senior oversight.

    Verbatim wording from the response

    “There is now a new Operational Team Lead in post and this member of staff has imbedded robust systems within the CMHT. The first change is the implementation of an Inbox based system to communicate discharge care plans to CMHT staff.”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 25 September 2017

    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

    Extend seven-day post-discharge follow-up to everyone discharged from hospital, not only people under the Care Programme Approach.

    Verbatim wording from the response

    “A seven day follow up following discharge from hospital is a key intervention and has now been extended to include all individuals following discharge from hospital, not just those under the Care Programme Approach.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require Senior Practitioners to allocate and monitor discharge-plan actions, using duty workers when care coordinators are unavailable.

    Verbatim wording from the response

    “Senior Practitioners are now responsible for ensuring that actions arising from discharge plans are allocated to care coordinators and monitored to ensure they have been followed up. This will include seven day follow ups, medical reviews and changes in medication. This new process will also allow senior practitioners to allocate actions to a duty worker if the care coordinator is absent from work or unable to undertake an intervention for any reason.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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

    Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.

    Verbatim wording from the response

    “With the systems that are now implemented at the CMHT I hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    Open published response

  6. Manchester South

    AI-generated summary

    Matthew Robert Edwards · 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

    Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.

    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 follow-up appointments are booked before discharge

    Wider context from the report

    “2. The follow up appointment was not made for Mr Edwards on his discharge. When the discharge summary was dispatched subsequently this was not picked up and there was no system in place to ensure that follow up appointments had been booked prior to discharge. ”

    Source location

    Matthew Robert Edwards · 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

    Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.

    Verbatim wording from the response

    “I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.”

    Source location

    Matthew-Edwards-Response
    Page 2 · response
    Published 17 July 2017

    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-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.

    Verbatim wording from the response

    “This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.”

    Source location

    Matthew-Edwards-Response
    Page 3 · response
    Published 17 July 2017

    Open published response

  7. Staffordshire South

    AI-generated summary

    Dean Mark Rowland · 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

    Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide follow-up after community mental health assessment

    Wider context from the report

    “(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. ”

    Source location

    Dean Mark Rowland · 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 assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.

    Verbatim wording from the response

    “When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    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 self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

    Verbatim wording from the response

    “Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    Open published response

  8. Inner South London

    AI-generated summary

    Jamie Pashley · 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

    Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    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 make telephone contact between discharge and first appointment review

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · 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

    Reliance on individuals to proactively manage their rehabilitation after discharge

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide fixed post-discharge appointments after detoxification

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

    Source location

    Jamie Pashley · 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

    Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.

    Verbatim wording from the response

    “The Trust’s view is that a more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient’s GP may be a more effective approach. There is currently a trial underway in which King’s College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    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

    Expanding telephone follow-up would require additional funding for the Trust’s alcohol dependency service.

    Verbatim wording from the response

    “As is the case with the provision of fixed appointments, the Trust recognises that making telephone contact in this interim period may be beneficial for some alcohol dependency patients. However, it is again unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 2 · response
    Published 4 August 2017

    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 motivational models and pre-discharge links to appropriate third-sector services are preferred over fixed hospital follow-up appointments.

    Verbatim wording from the response

    “Alcohol dependency patients have notoriously very high DNA rates. As a result, providing fixed follow-up appointments for this category of patients after detoxification as an in-patient and signposting would likely generate a high level of wasted appointments. This is why it is common practice within the NHS to instead use motivational models and to ensure patients as far as practicable are linked in with appropriate third-sector services prior to discharge rather than providing further hospital appointments.”

    Source location

    2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
    Page 1 · response
    Published 4 August 2017

    Open published response

  9. Black Country

    AI-generated summary

    Ms Abigail Baynham · 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

    Ms Abigail Baynham had a history of suicidal ideation and was found deceased at her flat after taking her own life. The inquest heard that no further referral to the Mental Health Liaison Service was made when she left hospital, which may have led to a further assessment of her mental state and risk of self-harm.

    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 make further referrals back to the Mental Health Liaison Service after hospital discharge

    Wider context from the report

    “1. Evidence emerged during the inquest that when Ms Baynham had left hospital on the 22 November 2017, there was no further referral made back to Mental Health Liaison Service. This may have triggered a further assessment about her mental state and risk of self-harm. ”

    Source location

    Ms Abigail Baynham · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Staffordshire South

    AI-generated summary

    Lester John STACEY · 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

    Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.

    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 visit and re-engage people who do not respond to appointment contacts

    Wider context from the report

    “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016. There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication. ”

    Source location

    Lester John STACEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to arrange follow-up appointments before discharge

    Wider context from the report

    “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016. There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication. ”

    Source location

    Lester John STACEY · 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.

Back to top

Data last updated 7 September 2026