Recurring concern

Unsafe implementation of early discharge pathways

First to latest report 19 Feb 2015 — 7 Jan 2016

Reports that mention this concern: 3
Times this concern has been raised: 5
Stated actions linked to this concern: 0

What this concern includes

Includes deficiencies in the design, communication, staffing, decision-making, family involvement, documentation, implementation, review or operation of an explicitly identified early discharge pathway when the deficiency can make discharge unsafe or inappropriate.

What is not included

Excludes generic staff training, communication or documentation failures that are not explicitly tied to an early discharge pathway or early-discharge decision.
Excludes discharge concerns concerning unrelated pathways, such as drug detoxification discharge, unless the assertion specifically concerns an early discharge pathway of the same kind.
Excludes post-discharge community-care deficiencies that do not concern the safe operation or decision-making of the early discharge pathway.
Excludes outcomes or individual inappropriate-discharge events unless they identify a recurring failure in the early discharge pathway.

Trends

Reports over time

Reports mentioning this concern, 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.

Barts Health NHS Trust1

Rotherham Doncaster and South Humber NHS Foundation Trust1

Royal London Hospital1

Sussex Partnership NHS Foundation Trust1

Reports and published responses 3 reports

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

7 Jan2016
West Sussex
Concerns raised2
1. Lack of a process for family members to provide views and information to early-discharge decision-makers
2. Lack of a process for family members to understand the reasons for discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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

Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early 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
Lack of a process for family members to provide views and information to early-discharge decision-makers
Wider context from the report
“(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for discharge. ”
Source location
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
Page 4 · 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 a process for family members to understand the reasons for discharge
Wider context from the report
“(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for discharge. ”
Source location
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
Page 4 · concerns
Open source report
1 Jun2015
South Yorkshire (Eastern)
Concerns raised2
1. Inadequacy of guidance incorporating the ethos and workings of the early discharge plan
2. Variable staff knowledge and understanding of the early discharge pathway
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Savo · 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

James Savo had a longstanding history of depression and died by hanging on 3 December 2013, four days after discharge from inpatient treatment. The concerns identified were insufficient communication with family and carers, inadequate consideration of family concerns and the timing of home-treatment input during discharge planning, and variable understanding and possible inadequacy of the early discharge pathway. The report also identified a lack of effective auditing to ensure communication systems were followed.

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
Inadequacy of guidance incorporating the ethos and workings of the early discharge plan
Wider context from the report
“(2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is clearly a system adopted locally and currently being re-evaluated, given it's significance in facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan. Witnesses knowledge and understanding of this pathway was variable. ”
Source location
James Savo · 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
Variable staff knowledge and understanding of the early discharge pathway
Wider context from the report
“(2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is clearly a system adopted locally and currently being re-evaluated, given it's significance in facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan. Witnesses knowledge and understanding of this pathway was variable. ”
Source location
James Savo · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Feb2015
London Inner (North)
Concerns raised1
1. Inappropriate early discharge home following MDT meetings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John DACK · 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

John Dack sustained fractures to both ankles, underwent procedures and was discharged home unable to weight bear without the planned follow-up. He later developed an infected left ankle with osteomyelitis and died on 24 September 2014 after hospital treatment. The report’s principal concern was that an incorrect address in his medical notes prevented follow-up despite notifications from his daughter; it also raised concern about early discharge home after the MDT meeting.

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
Inappropriate early discharge home following MDT meetings
Wider context from the report
“(No witness was able to offer any suggestions for changes to the hospital system that might prevent inappropriate early discharge home following MDT meeting on another occasion.) ”
Source location
John DACK · Prevention of Future Deaths report
Page 2 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Lack of a process for family members to provide views and information to early-discharge decision-makers

Lack of a process for family members to understand the reasons for discharge

Concerns raised2

Inadequacy of guidance incorporating the ethos and workings of the early discharge plan

Variable staff knowledge and understanding of the early discharge pathway

Concerns raised1

Inappropriate early discharge home following MDT meetings