Recurring concern

Unreliable consultant review of patients unexpectedly returning after discharge

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First reported 11 Nov 2019•Latest report 11 Jan 2023

Definition

What this concern includes

Includes failures in arrangements for identifying unexpected returns after discharge and ensuring timely consultant notification, discussion or review, including system design, guidance, staff understanding, communication, documentation and escalation controls directly dedicated to those returns.

Not included

Excludes general consultant-review delays or failures where the patient did not unexpectedly return after discharge.
Excludes generic discharge communication, clinical handover, record-keeping or staffing deficiencies unless they directly impair the consultant-review process for unexpected post-discharge returns.
Excludes failures in the underlying assessment or treatment of a patient after a consultant has been reliably informed and involved.
Excludes routine planned follow-up or ordinary readmissions that are not unexpected returns requiring the dedicated consultant-review safeguard.

Reports: 2
Individual concerns: 2
Date range: 2019–2023
Stated actions: 3

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.

George Eliot Hospital NHS Trust1

Spire Bristol Hospital1

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.

11 Jan2023
Warwickshire
Concerns raised1
1. Lack of familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours
This report raised 6 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 2
1. Action
  Work with Information Technology to add a 72-hour reattendance alert requiring consultant advice before discharge.
  Stated by George Eliot Hospital NHS TrustStated in progress
2. Action
  Audit patients reattending within 72 hours for consultant referral before discharge and share the findings within UEC and at Trust-wide Audit Day.
  Stated by George Eliot Hospital NHS TrustStated in progress
Respondent positions 1
1. Position
  Overseas-qualified doctors undergo Royal College accreditation, including assessment of familiarity with relevant guidance, on the same basis as UK-trained doctors.
  Stated by George Eliot Hospital NHS TrustDisputes the concern
AI-generated summary

Carol Ann Welch · 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

Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.

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 familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours
Wider context from the report
“(1) The subsequent investigation by GEH highlighted two areas which needed addressing: • The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings. This had been done by means of discussions in meetings and a poster displayed in a staff area. • Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department. This had been done by circulating an aide memoire to be given to those in training and existing members of the department. ”
Source location
Carol Ann Welch · 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
Work with Information Technology to add a 72-hour reattendance alert requiring consultant advice before discharge.

Verbatim wording from the response
“The Trust has, however, noted that the middle grade doctor in question did not follow the appropriate guidance of referring to a consultant if a patient returns to the department within 72 hours with the same clinical condition. The Trust is currently working with its Information Technology Department to add an alert to the Clinical Portal used by UEC to flag/highlight if the patient reattends within 72 hours and mandate that the doctor should seek advice from a consultant prior to discharging the patient from the department. We believe this additional safety measure would prevent future harm in this group of patients who are at higher risk.”

Source location
Response from George Eliot Hospital
Page 4 · response
Published 16 January 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
Audit patients reattending within 72 hours for consultant referral before discharge and share the findings within UEC and at Trust-wide Audit Day.

Verbatim wording from the response
“UEC are in the process of conducting an audit to review patients that have reattended within 72 hours to see whether they were referred to a consultant prior to discharge. The outcome of this review will be shared within UEC and will also be presented at the Trust Wide Audit Day.”

Source location
Response from George Eliot Hospital
Page 4 · response
Published 16 January 2023
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
Overseas-qualified doctors undergo Royal College accreditation, including assessment of familiarity with relevant guidance, on the same basis as UK-trained doctors.

Verbatim wording from the response
“When the Trust receives an application from a doctor our People and Recruitment Department will check the official GMC registration to ensure the doctor is appropriately registered and holds the relevant qualifications and license to practice in the UK. The doctor in Mrs Welch’s case was registered with the GMC in April 2020. In addition, this doctor became a member of the Royal College of Emergency Medicine before they started working at this Trust in September 2020. Accordingly, the doctor will have been assessed as competent by the Royal College as part of their registration and accreditation process in exactly the same way a UK trained doctor would be assessed. This accreditation includes an assessment of familiarity with relevant Royal College guidance.”

Source location
Response from George Eliot Hospital
Page 2 · response
Published 16 January 2023
Open published response
11 Nov2019
Avon
Concerns raised1
1. Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after 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 1
1. Action
  Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
  Stated by Spire Bristol HospitalStated completed
Respondent positions 1
1. Position
  Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
  Stated by Spire Bristol HospitalExisting arrangements considered sufficient
AI-generated summary

Antonis Tofali Hannides · 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

Antonis Tofali Hannides died on 29 March 2019 from liver and heart disease after undergoing hernia repair and subsequently reattending hospital with confusion. Concerns included the lack of a formal system for managing unexpected reattendance after discharge, inadequate documentation, and failure to inform his consultant immediately.

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 immediate informing of consultants about patients who reattend unexpectedly after discharge
Wider context from the report
“No formal system at Spire Bristol for 1) Seeing patients who reattend unexpectedly after discharge; 2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance; 3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge. ”
Source location
Antonis Tofali Hannides · 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
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.

Verbatim wording from the response
“In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannides’ case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients’ consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented.”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 2 · response
Published 27 December 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 admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.

Verbatim wording from the response
“It is anticipated that some patients who have undergone treatment at a Spire Hospital may contact the Hospital with enquiries about their care after discharge. As such, Spire Healthcare has an Admission and Discharge policy (in place at the time of Mr Hannides’ admission) which outlines a number of key steps that must take place as part of any patients’ discharge planning process, to ensure that patients are supported after they leave hospital and are aware of how to seek advice if they have concerns.”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 1 · response
Published 27 December 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after 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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 1