Recurring concern

Failure to maintain follow-up of patients who disengage from care

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First reported 23 Jul 2013•Latest report 1 Oct 2025

Definition

What this concern includes

Includes failures of a patient follow-up or contact process involving non-compliance, non-contact, disengagement or loss to follow-up, including failures to initiate further contact, escalate concerns or maintain continuity across services.

Not included

  • Excludes routine delays in follow-up where patient disengagement or non-contact is not material to the concern.
  • Excludes failures concerning a specific diagnostic, treatment or appointment process unless the report identifies loss of patient follow-up as the shared unsafe condition.
  • Excludes generic staffing, training, documentation or governance deficiencies not explicitly tied to maintaining follow-up of disengaged patients.
Reports
23

Distinct published reports

Individual concerns
23

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
29

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.

NHS England3
Care Quality Commission2
Essex Partnership University NHS Foundation Trust2
Midlands Partnership University NHS Foundation Trust2
Avenue House Nursing and Care Home1
Bexley Medical Group1
Bury Borough Council1
CAMHS East – Cross Street Clinic1
Care UK1
City Health Care Partnership CIC1
Community Mental Health Recovery Services (Surrey and Borders Partnership)1
CRG Medical Services1
Digital Health and Care Wales1
Droylsden Road Family Practice1
Gloucestershire Health and Care 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.

  1. Gloucestershire

    AI-generated summary

    MARTIN LEE TILLEY · 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 Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary mental health services.

    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 follow up patients after missed mental health appointments

    Wider context from the report

    “Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team. Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017. ”

    Source location

    MARTIN LEE TILLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. 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
  3. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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 proactive follow-up after a declined appointment

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Nottinghamshire

    AI-generated summary

    Sheila Stokes · 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

    Sheila Stokes had a large abdominal aortic aneurysm diagnosed in July 2015 and died at home on 26 January 2016 after it ruptured. The report identified delays in arranging appointments, acting on the radiology alert, discussing the case, and sending information needed for a custom-made graft. It also raised concerns about administrative systems, communication, the trust’s investigation, and the completeness of statements provided to the coroner.

    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 contact and follow up patients who DNA appointments

    Wider context from the report

    “1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to be copied to their GPs. ”

    Source location

    Sheila Stokes · 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

    Relaunch and standardize the Trust-wide DNA process, including same-day clinician review, documented actions, safeguarding escalation, and GP notification on discharge.

    Verbatim wording from the response

    “The DNA process was re-launched in June 2016 (see the flow chart attached) as it was clear that there was not a consistent approach to dealing with DNAs across the Trust. This process ensures that DNAs are dealt with on the day. Clinic staff will place a DNA sticker into the patient’s notes and ensure this is completed by the clinician who indicates the action to be taken e.g. further appointment within given timescale or discharge. The clinician can also highlight if there are any safeguarding concerns and request the notes to be returned to their Patient Pathway Co-ordinator (PPC) for further action to be taken.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 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

    Conduct regular audits of the DNA process to verify adherence.

    Verbatim wording from the response

    “A number of managers involved in the Outpatient service carry out DNA audits on a regular basis to ensure that the process is being adhered to. We are happy to provide audits of this process should you require.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 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

    Pilot scanning DNA reconciliation slips into Medway to create a permanent record of requested actions.

    Verbatim wording from the response

    “The receptionist will input an outcome for the appointment and makes any further appointments as requested by the clinician before sending the notes to the PPC. If the patient is discharged at the clinician’s request a DNA letter will be sent to both the patient and their GP to indicate the discharge has taken place. However, prior to discharging the patient a check is made to ensure that the patient was sent an appointment letter and also that the address for the patient recorded on Medway, matches that on the Summary Care Record. The reconciliation slips which indicate the actions requested by the clinician are destroyed after completion of the task. However, the DNA sticker remains within the case notes permanently and is a record of the request. The Trust is planning to commence a pilot of scanning reconciliation slips into Medway, providing a permanent record.”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 February 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

    An earlier vascular appointment could not be provided because clinic capacity was limited during the relevant period.

    Verbatim wording from the response

    “Mrs S did not attend this appointment and this was inputted onto our system as a ‘DNA’ and she was to have a new appointment made (see appendix 3). We believe that our staff telephoned Mrs S the following day (28th July) to make another appointment for her which was for the 14th September and from the comment made, it was noted that she would like to be seen earlier if there was opportunity by reason of a cancellation (see appendix 4). We believe that it is likely that this date of 14 ████████”

    Source location

    2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 February 2017

    Open published response
  5. City of London

    AI-generated summary

    Nathan Anthony Lowe · 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

    Nathan Anthony Lowe was discharged from hospital and a Section 2 Mental Health Act Order in October 2015, with community psychiatric follow-up arranged. He fell to his death in central London on 12 May 2016; the concern was whether more should have been done to contact him between 10 March and 12 May given his illness and non-compliance with follow-up.

    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

    Insufficient contact with a patient who is non-compliant with follow-up

    Wider context from the report

    “Whether or not more should have been done to make contact with the patient between the 10th March and 12th May given the nature of his illness and the fact of his non-compliance with follow up. Such consideration is relevant to a Coroner’s duty in connection with the prevention of future deaths ”

    Source location

    Nathan Anthony Lowe · 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

    Strengthen team leadership and oversight of follow-up and multidisciplinary decision-making for service users with complex needs.

    Verbatim wording from the response

    “I am aware that immediately following completion of the serious incident report the Service Line Lead responsible for this Quadrant met with the North West Adult community team members to discuss the learning and take the opportunity to personally review existing processes to look at ways in which the multi-disciplinary ways of working could be strengthened. The following actions have been taken since that time:”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    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

    Record clear actions, deadlines and responsible leads from multidisciplinary meetings in meeting notes and electronic service-user records.

    Verbatim wording from the response

    “3. Clear actions and timeframes by when these actions will be completed and by whom, are now more clearly recorded in the notes of each MDT meeting. These actions and associated timeframes and leads are also recorded in the service users’ electronic record.”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    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

    Review care-coordinator caseloads to identify further actions required.

    Verbatim wording from the response

    “5. A review of the care coordinators case load is being undertaken to identify if there are any further areas where actions may need to be taken”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    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

    Pilot a clinical zoning tool in two community teams to identify high-risk service users requiring increased monitoring and intervention.

    Verbatim wording from the response

    “6. A clinical zoning tool is being piloted in two community teams including the North West. Through training this will assist in identifying those service users in each of the community teams who have high risk factors that require increased monitoring and interventions by the multi-disciplinary members of the clinical team.”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    Open published response
  6. Inner North London

    AI-generated summary

    Terence Darren ADAMS · 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 Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

    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 follow up non-attendance at the second reception screen

    Wider context from the report

    “5. On the morning he died, Mr Adams should have attended his second reception screen, also known as the well man clinic. When he did not arrive, the healthcare nurse did not attempt to find out why or to secure his attendance. ”

    Source location

    Terence Darren ADAMS · Prevention of Future Deaths report
    Page 2 · 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

    Nurses cannot chase prisoners who miss appointments during clinics because workload makes this impractical and inefficient.

    Verbatim wording from the response

    “When a patient is booked for a clinic but does not attend (DNA), nurses will investigate and chase up that person once the clinic is over. It would not be possible, nor an efficient use of clinical time, for nurses to chase up prisoners during the course of a clinic. With 15-20 new receptions everyday (Pentonville being a remand prison and thus having a high population turnover), if nurses chased up DNA prisoners during the course of the clinic, they would spend their time doing nothing else.”

    Source location

    Response from Care UK
    Page 4 · response
    Published 26 July 2016

    Open published response
  7. Leicester City and South Leicestershire

    AI-generated summary

    Barry Thraves · 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

    Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and 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 respond to non-attendance with clinical risk consideration

    Wider context from the report

    “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time. ”

    Source location

    Barry Thraves · 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

    Remind community mental health staff to follow the Did Not Attend policy for missed appointments.

    Verbatim wording from the response

    “Actions taken/planned:”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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

    Conduct regular spot checks of compliance with the Did Not Attend policy.

    Verbatim wording from the response

    “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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

    Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.

    Verbatim wording from the response

    “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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

    Circulate an interim missed-appointment flow chart to community mental health teams.

    Verbatim wording from the response

    “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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

    Contact new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.

    Verbatim wording from the response

    “Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required. A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up.”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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

    Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.

    Verbatim wording from the response

    “Since the beginning of November 2015 what are known as ‘open contacts’ on the patient electronic record (RiO) are being monitored on a weekly basis. This is where a patient has had an appointment date that has passed but the episode of care has not been closed on the record, either by a record of the appointment having taken place or evidence of a further appointment offered. These will be drawn to the”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    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 compliance with the Did Not Attend policy during quarter two of 2016/17.

    Verbatim wording from the response

    “We have informed our entire medical and nursing staff, in writing dated 1 December 2015 that they MUST write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.”

    Source location

    2015-0443-Response2
    Page 4 · response
    Published 26 October 2015

    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 concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.

    Verbatim wording from the response

    “This concern relates to Leicestershire Partnership Trust’s involvement with Mr Thraves and I am aware that the Trust will be responding to you on this point.”

    Source location

    2015-0443-Response
    Page 1 · response
    Published 26 October 2015

    Open published response
  8. Manchester West

    AI-generated summary

    Suzanne Samantha Greenwood · 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

    Suzanne Samantha Greenwood died at Haslam Park, Bolton, on 23 December 2014 after being found collapsed and unresponsive with a ligature around her neck; she had also taken Zopiclone and alcohol. The principal concerns were the absence of contact after she failed to attend appointments, her not being discharged or reported to her General Practitioner, and the lack of systems and timescales for managing missed appointments and notifying other healthcare professionals.

    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 contact patients after missed appointments

    Wider context from the report

    “1. During the Inquest evidence was heard that i. Mrs Greenwood had not been seen by ████████ at the Priory Hospital, Altrincham after her last review on the 21st November 2013 prior to her death on the 23rd December 2014. She had failed to attend appointments in January 2014 but there had been no contact with her, either by telephone or letter, following her failure to attend the appointment on the 16th January 2014. ii. Mrs Greenwood had not been discharged by ████████ following her failure to attend her appointment on the 16th January 2014 and before her death on the 23rd December 2014 but there had been no contact with her for a period exceeding 11 months. iii. ████████ had not made any contact with the General Practitioner to confirm Mrs Greenwood’s failure to attend her appointments in January 2014 and that she had not been seen after the 21st November 2013, which is a particular concern when an Advanced Nurse Practitioner reduced the medication initially prescribed by ████████ which she had the authority to reduce, in circumstances where ████████ had not seen Mrs Greenwood since the 21st November 2013. iv. There are no systems, either in ████████ private practice or in the Priory Hospital, Altrincham to contact patients following a failure to attend appointments and to consider the discharge of patients when a patient repeatedly fails to attend appointments over a period of time. There are no timescales with regard to the discharge of patients and no system to contact General Practitioners or other health professionals in relation to the failure to attend appointments, particularly in circumstances where other health professionals are likely to continue to treat patients after the missed appointments, including changes in medication. The importance of discharge within a reasonable period after a failure to attend appointments is important to enable other health professionals involved in continuing care to be aware of the non-attendance at appointments and the discharge. The fact that there has been no reported failure to attend appointments and no reported discharge would be misleading to other health professionals involved in continuing care, particularly when a patient has not been seen for a period in excess of 12 months and that information would not be available to other health professionals in the absence of information from the Hospital. There is a need for health professionals involved in the continuing care of a patient to be kept informed as to the treatment or non-treatment of the patient at a hospital when considering further treatment in the community. 2. I request you to consider the above concerns and for both ████████ and The Priory Hospital, Altrincham to carry out a review with regard to the following. i. The systems procedures, policies and protocols in relation to contact with patients who fail to attend appointments. ii. The systems, procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that the patient will be discharged unless there is either contact or an appointment within a defined period. iii. The systems, procedures, policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments with notification to General Practitioners or other health professionals of the patient’s failure to attend appointments and their discharge from hospital. The review should consider timescales in relation to discharge when a patient has failed to attend appointments for a specific period of time. iv. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. ”

    Source location

    Suzanne Samantha Greenwood · 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

    Complete a review of systems, procedures, policies and protocols governing contact with patients who fail to attend appointments.

    Verbatim wording from the response

    “1. You asked that a review is carried out of the systems, procedures, policies and protocols in relation to contact with patients who fail to attend appointments.”

    Source location

    2015-0370-Response-by-The-Priory_Redacted
    Page 1 · response
    Published 9 October 2015

    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 independent doctors to send final non-attendance letters to patients and relevant professionals, including medication, aftercare, crisis actions and future assistance options.

    Verbatim wording from the response

    “In response to 2 and 3 please note that we have given full consideration to these matters and have now made the following requirements explicit in Policy H105: Practising Privileges for Independent Doctors:”

    Source location

    2015-0370-Response-by-The-Priory_Redacted
    Page 2 · response
    Published 9 October 2015

    Open published response
  9. Surrey

    AI-generated summary

    George Nigel Palmer · 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

    George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be 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 ensure appropriate follow-up letters to patients after non-contact

    Wider context from the report

    “During the inquest ████████ Registered Mental Health Nurse, provided helpful evidence and the following concerns were highlighted: - • Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. • Appropriateness of follow up letters to the patient in the event of non-contact. I would ask that you consider giving further consideration to the above to ensure that there is no further repetition. ”

    Source location

    George Nigel Palmer · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. 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
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Data last updated 7 September 2026