Recurring concern

Unreliable communication of discharge medication information to care staff

First to latest report 20 Aug 2013 — 4 Mar 2024

Reports that mention this concern
8
Times this concern has been raised
8
Stated actions linked to this concern
8

What this concern includes

Includes failures in the discharge process to record, communicate, transfer or confirm receipt of patient-specific medication information needed by staff or services responsible for medication administration, prescribing, monitoring or follow-up after discharge.

What is not included
  • Excludes failures to supply, dispense or physically provide the correct medication at discharge when medication information communication is not deficient.
  • Excludes general discharge summaries, follow-up arrangements or clinical information unless the asserted unsafe condition specifically concerns discharge medication information.
  • Excludes medication prescribing, reconciliation, administration or monitoring failures occurring after accurate discharge medication information has been communicated.
  • Excludes generic record-keeping, communication or staffing deficiencies without a material discharge-medication-information context.

Reports and published responses 8 reports

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

  1. Mid Kent and Medway

    AI-generated summary

    Sarah Rhiannon Keen · 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

    Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.

    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 document and communicate discharge medication recommendations

    Wider context from the report

    “(2) The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that Sarah’s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide Sarah with any medication on the basis that there was already a prescription in the community and although he considered that it was appropriate for the quantity of discharge medication to be reduced to seven days to reduce the risk of overdose, he did not communicate this to the medical team within the note. ”

    Source location

    Sarah Rhiannon Keen · 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

    Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.

    Verbatim wording from the response

    “• The discharging clinician (both or either DGT and KMPT) should record if a reduced amount of medication should be prescribed because of risk of self-harm or overdose.”

    Source location

    Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
    Page 2 · response
    Published 14 March 2024

    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

    State in discharge notifications when medication has been reduced and record the reason.

    Verbatim wording from the response

    “• The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.”

    Source location

    Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
    Page 2 · response
    Published 14 March 2024

    Open published response

  2. Milton Keynes

    AI-generated summary

    Jacqueline Anne CARREY · 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

    Jacqueline Anne CARREY was admitted to Milton Keynes University Hospital with severe pancreatitis pain, discharged with an excess of medication, and found deceased at home on 25 May 2023; the inquest conclusion was drug related. The principal concern was that risks of medication abuse may not have been clearly recorded or flagged before discharge, raising concerns about medication distribution and patient-record procedures.

    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 flag potential medication-use risks to staff before discharge

    Wider context from the report

    “There may not have been a clear indication on the patients medical record about the potential risk of ████████ abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing ████████ medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of ████████ medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding ████████ use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths. ”

    Source location

    Jacqueline Anne CARREY · 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

    Review the electronic health record for proportionate additional safety measures affecting discharge medication processes.

    Verbatim wording from the response

    “In addition to using Mrs Carrey’s case for awareness raising and education within the broad pharmacy team, we have reviewed our EHR to determine whether additional safety steps can be incorporated in such a way as they do not negatively impact the timeliness of high-volume processes in a disproportionate way.”

    Source location

    Response from Milton Keynes University Hospital
    Page 3 · response
    Published 1 November 2023

    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

    Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.

    Verbatim wording from the response

    “We have been able to incorporate new measures which – at their core – codify information / recommendations around the restriction of medicines supplied at discharge (i.e., exceptions to the contractual 14-day supply expectation). The ‘Pharmacy Medication History Form’ now includes the question ‘Does this patient get a limited supply in community’, requiring a ‘yes’ or ‘no’ answer. The user can still add free text narrative but the fact of selecting ‘yes’ in response to this question fires specific actions downstream when clinicians are looking to progress the patient’s discharge.”

    Source location

    Response from Milton Keynes University Hospital
    Page 4 · response
    Published 1 November 2023

    Open published response

  3. Liverpool and the Wirral

    AI-generated summary

    Lewis James Doyle · 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

    Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary 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 original prescribers with information about suspended or stopped medication

    Wider context from the report

    “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers. ”

    Source location

    Lewis James Doyle · 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

    Fund EPMA implementation in an additional 25 NHS trusts.

    Verbatim wording from the response

    “The use of Dictionary of medicines and Devices (dm+d), (a dictionary of descriptions and codes for medicines and devices in use across the NHS), compliant Electronic Prescribing and Medicines Administration (EPMA) systems makes the process of sending and receiving medicines related information between organisations and health professionals easier and more accurate. It is recognised that this would improve patient safety and hence there is now no national funding to support its roll out. I can confirm that NHS E/I provided funding for an additional 25 Trusts to have EPMA in this last week. The information standards for digital transfer of care do include changes to medicines albeit optional at present. These will be used for the basis for transfer of care in the future (PRSB standards https://theprsb.org/standards/edischarge summary/)”

    Source location

    2019-0214-Response-from-NHS-England-and-NHS-Improvement
    Page 2 · response
    Published 23 August 2019

    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

    Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.

    Verbatim wording from the response

    “Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP. The discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this – in line with recommendations from the Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB).¹”

    Source location

    2019-0214-Response-from-NHS-England-and-NHS-Improvement
    Page 2 · response
    Published 23 August 2019

    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 legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.

    Verbatim wording from the response

    “I am advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared.”

    Source location

    2019-0214-Response-by-Department-of-Health-and-Social-care
    Page 2 · response
    Published 23 August 2019

    Open published response

  4. West London

    AI-generated summary

    PATRICIA PRISCILLA CHAMBERS · 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

    Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.

    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 communicate the Discharge Medication Summary to relevant parties

    Wider context from the report

    “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”

    Source location

    PATRICIA PRISCILLA CHAMBERS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Peter STOJILJKOVIC · 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

    Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.

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    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 communicate with community GPs before discharge about ongoing melatonin prescribing

    Wider context from the report

    “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community; 2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. 4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. 5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community. ”

    Source location

    Peter STOJILJKOVIC · 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

    Review the case with the practice to identify further learning.

    Verbatim wording from the response

    “1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning.”

    Source location

    2018-0077-Response-by-NHS-England
    Page 1 · response
    Published 16 June 2018

    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

    Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.

    Verbatim wording from the response

    “4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”

    Source location

    2018-0077-Response-by-NHS-England
    Page 2 · response
    Published 16 June 2018

    Open published response

  6. Suffolk

    AI-generated summary

    Rachel Holly 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

    Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

    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 reliably notify GPs of discharge medication types and quantities

    Wider context from the report

    “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’. ”

    Source location

    Rachel Holly 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

    Plan the technical changes required to notify GPs electronically about prescribed discharge medication.

    Verbatim wording from the response

    “You raised the matter that there was no automated notification to the service user’s GP of the type and amounts of prescribed medication issued at the point of discharge. This information is crucial to help reduce the potential of over prescribing. You heard that the current process involves human action through use of emails.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 30 April 2024

    Open published response

  7. County Durham and Darlington

    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 communicate the discharge medication safety arrangement to the consultant psychiatrist

    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

  8. South London

    AI-generated summary

    Nicola Matthews · 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

    Nicola Matthews took an overdose of medication after leaving hospital on 15 October 2010 and was found unrousable at her partner’s home in the early hours of 16 October, later being pronounced dead in hospital. The principal concern was that decisions about her discharge, including follow-up arrangements and the nature and quantity of medication supplied, were unclear and inadequately documented or communicated.

    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 discharging staff with clear information about medication supplied at discharge

    Wider context from the report

    “My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital. The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner. In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged. I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented. ”

    Source location

    Nicola Matthews · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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

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Data last updated 7 September 2026