Recurring concern

Unreliable receipt, prioritisation and clinical review of hospital discharge summaries

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First reported 10 Oct 2013•Latest report 3 Mar 2016

Definition

What this concern includes

Includes failures in receiving, identifying, triaging, prioritising, reviewing or actioning hospital discharge summaries within the receiving care service, including failure to distinguish summaries involving serious injuries or other urgent follow-up needs.

Not included

  • Excludes deficiencies in preparing, completing or transmitting discharge summaries from the discharging hospital where the receiving-service process is not deficient.
  • Excludes clinical failures after a discharge summary has been reliably received, appropriately prioritised and reviewed.
  • Excludes generic primary-care workload, record-keeping or communication deficiencies unless they directly impair receipt, prioritisation or clinical review of hospital discharge summaries.
  • Excludes discharge planning, medication reconciliation and post-discharge care failures where no hospital discharge-summary receipt or review problem is identified.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2016

First to latest report issue date

Stated actions
0

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.

Nuffield Road Medical Centre1
Wibsey and Queensbury Medical Practice1

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. West Yorkshire (Western)

    AI-generated summary

    Christopher John Stubbs · 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 John Stubbs, who had a history of mental ill health and drug misuse, was found suspended from a ligature at his home on 26 July 2015, and the inquest concluded that he died by suicide from hanging. A concern was raised that medication stopped after his earlier overdose was not reviewed by his GP before his death, and about systems for receiving hospital discharge summaries advising on medication review.

    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 of office systems and procedures to ensure receipt of hospital discharge summaries advising medication review

    Wider context from the report

    “During the course of the inquest I heard that Christopher’s prescribed medication of mirtazapine and pregabalin was stopped by the acute hospital doctors on his discharge from the hospital following his overdose of 7 February 2015, pending a further review by his GP, which I heard did not take place prior to his death. • To review the effectiveness of existing office systems and procedures in relation to the receipt of discharge summaries from hospitals which advise on the review of patient’s medication. ”

    Source location

    Christopher John Stubbs · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Cambridgeshire (South and West)

    AI-generated summary

    James Edward Mansfield · 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 Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

    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 receiving and reviewing hospital discharge summaries

    Wider context from the report

    “(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that the hospital post discharge letters to your surgery. This was not received until 28th February 2013 by which time Mrs Mansfield had called requesting stronger pain killers. The discharge summary was only reviewed by a doctor on 6 March. You stated that only if a patient was admitted to hospital would their discharge letter get prompt attention. There was no apparent method for differentiating between discharge summaries which involved serious injuries and those which did not. ”

    Source location

    James Edward Mansfield · 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

    Lack of differentiation and prioritisation of serious-injury discharge summaries

    Wider context from the report

    “(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that the hospital post discharge letters to your surgery. This was not received until 28th February 2013 by which time Mrs Mansfield had called requesting stronger pain killers. The discharge summary was only reviewed by a doctor on 6 March. You stated that only if a patient was admitted to hospital would their discharge letter get prompt attention. There was no apparent method for differentiating between discharge summaries which involved serious injuries and those which did not. ”

    Source location

    James Edward Mansfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026