Recurring concern

Failure to ensure patients receive the correct prescribed medication at hospital discharge

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First reported 4 Sep 2013•Latest report 17 Oct 2023

Definition

What this concern includes

Includes failures in the hospital discharge medication process that prevent the patient receiving the correct prescribed medication before or at discharge, including transfer, dispensing, availability, reconciliation and escalation failures dedicated to discharge medication safety.

Not included

Excludes failures to administer medication during an inpatient stay when they are not connected to discharge.
Excludes prescribing, clinical selection or dose-assessment failures that do not concern supplying or transferring medication at discharge.
Excludes generic discharge communication failures involving summaries, results or other information without a medication-supply failure.
Excludes medication-access or dispensing risks outside hospital discharge.

Reports: 13
Individual concerns: 13
Date range: 2013–2023
Stated actions: 13

Reports 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.

Derriford Hospital1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Grasmere Surgery1

Greater Manchester Mental Health NHS Foundation Trust1

Hull University Teaching Hospitals NHS Trust1

Leeds Teaching Hospitals NHS Trust1

Manchester University NHS Foundation Trust1

Mid Yorkshire Teaching NHS Trust1

Pennine Acute Hospitals NHS Trust1

Tameside and Glossop Integrated Care NHS Foundation Trust1

Tees, Esk and Wear Valleys NHS Foundation Trust1

the Shrewsbury and Telford Hospital NHS Trust1

University Hospitals of Leicester NHS Trust1

University Hospitals Plymouth NHS Trust1

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust1

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.

6 Aug2014
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to provide prescribed medication at hospital discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Martin Rowland HILL · 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

Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his 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 provide prescribed medication at hospital discharge
Wider context from the report
“(5) An additional concern arose separate to this. Mr Hill, when he was discharged on the 20th April, had been prescribed medication. Mr Hill should have left the hospital with that medication but none was provided to him. It is unlikely that its absence had any material effect in this case but it could in others. ”
Source location
Martin Rowland HILL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
24 Sep2013
County Durham and Darlington
Concerns raised1
1. Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide
Wider context from the report
“(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this. ”
Source location
Linda Hudson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
4 Sep2013
Leicester City and South Leicestershire
Concerns raised1
1. Failure to provide prophylactic antibiotic medication at discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.
  Stated by University Hospitals of Leicester NHS TrustStated planned
2. Action
  Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.
  Stated by University Hospitals of Leicester NHS TrustStated planned
3. Action
  Remind the junior doctors involved to fully consider patients’ pre-admission medication.
  Stated by University Hospitals of Leicester NHS TrustStated planned
AI-generated summary

Karen Lesley SUTTON · 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

Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

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 prophylactic antibiotic medication at discharge
Wider context from the report
“(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012. (4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. ”
Source location
Karen Lesley SUTTON · 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
Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
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
Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
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 the junior doctors involved to fully consider patients’ pre-admission medication.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide prescribed medication at hospital discharge

Concerns raised1

Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide

Concerns raised1

Failure to provide prophylactic antibiotic medication at discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 3