21 May 2025 Malcolm Morris · Prevention of Future Deaths report Northumberland
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Concerns raised 2
Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services View source Failure of hospital systems to enable electronic referrals to community nursing services outside the usual geographical area View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Develop and lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
View source
NHS England
Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.
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Malcolm Morris · 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
Malcolm Morris developed lymphoedema after surgery for penile cancer and died on 5 January 2024 after collapsing with right-thigh pain. The report raises concerns about hospitals being unable to electronically refer patients living outside their usual catchment area to community nursing services, resulting in inadequate discharge information and delayed or absent support for wound and catheter care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services
Wider context from the report “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service .
As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.
Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible.
This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents .
In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.
My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.
Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.
The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.
” Source location Malcolm Morris · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of hospital systems to enable electronic referrals to community nursing services outside the usual geographical area
Wider context from the report “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland . They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service.
As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.
Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible .
This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents.
In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.
My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.
Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.
The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services . Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.
” Source location Malcolm Morris · Prevention of Future Deaths report
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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 Develop and lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Verbatim wording from the response “Over the past three years, NHS England has developed and led ‘The Frontline Digitisation’ (FLD) Programme, which has supported trusts in adopting electronic patient record (EPR) systems, and which nationally supports increased consistency in digital maturity and improves information sharing between and within organisations.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.
Verbatim wording from the response “To further support more consistent interoperability across the NHS, NHS England has developed the ‘Booking and Referral Standard’ (BaRS), which is a national framework designed to help digitise and standardise referrals and bookings across care settings, including urgent and emergency care (UEC), general practice, hospital, and community services.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interoperability configuration and management are assigned to local provider organisations and regional centres, rather than being led nationally by NHS England.
Verbatim wording from the response “The FLD Programme not only enables organisations to purchase EPRs but also advises on safe and effective deployment. However, whilst FLD enhances local digital capabilities, interoperability (i.e. how different digital systems communicate with one another) is typically configured and managed at a local level, rather than being led nationally by NHS England. This will be based on local arrangements between provider organisations and regional centres, will be cognisant of the wider catchment area and will depend on the range of technology suppliers. As such, interoperability will vary depending on local infrastructure and information governance arrangements.” Source location Response from NHS England
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29 Jan 2025 Naomi SULEYMAN · Prevention of Future Deaths report Inner South London
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Concerns raised 2
Failure to make accurate referrals to the District Nursing team View source Delays in District Nursing assessment after referral View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Naomi SULEYMAN · 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
Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make accurate referrals to the District Nursing team
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge . This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them.
” Source location Naomi SULEYMAN · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in District Nursing assessment after referral
Wider context from the report “(1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge. This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them .
” Source location Naomi SULEYMAN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and disseminate an escalation and information-sharing pathway across community services, with ongoing monitoring and audit.
Verbatim wording from the response “• There is now an established pathway, for escalation of concerns and information sharing between community services (Podiatry, District nursing and Community therapies/Enablement). This information has been shared across the services and embedded at all levels and will be monitored and audited moving forward.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training for community therapy services and District Nurses on available services and referral procedures.
Verbatim wording from the response “• Additionally, training sessions will be initiated for community therapy services and district nurses and delivered between April and June 2025 to enhance awareness of available services and referral procedures.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular Discharge to Assess–District Nursing meetings and a communication champion to oversee information exchange and care-plan adherence.
Verbatim wording from the response “• In response to the report highlighting limited communication between the Discharge to Assess team and District Nurses, regular meetings have already been established between the teams to ensure consistent exchange of patient information. A staff member, or communication champion, has been appointed to oversee this process and ensure that care plans are followed. These communication efforts are being actively monitored and evaluated to confirm their effectiveness in preventing any future issues.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The District Nursing referral was timely and correctly recorded both the foot ulcers and sacral ulcer, contrary to the concern.
Verbatim wording from the response “• On further investigation the District Nursing referral was done in a timely way from the ward on the day of discharge and received and actioned by the DN team. The referral noted both the foot ulcers and the sacral ulcer correctly.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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13 Mar 2024 Alan William Rowland Smith · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Delays in referral for District Nursing input View source Lack of understanding of the need for prompt referral to District Nursing services View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Alan William Rowland Smith · 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
Alan William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in referral for District Nursing input
Wider context from the report “3. The inquest was told that as well as referral to vascular services it was important that GPs understood that District Nurses were a resource that should be utilised with prompt referrals. This could be challenging as the District Nursing Service was under huge pressure due to demand. However, they were well used to recognising high risk patients and clearer referrals for GPs around when to refer would ensure that their expertise would be available at an early stage . Management of any case such as Mr Smith’s would of necessity involve the District Nursing Team as compression bandaging was the most effective treatment to prevent a critical situation such as Mr Smith’s arising and the District Nurses were best placed to provide this. In Mr Smith’s case the referral for District Nursing input was not until a very late stage even though the GP had identified at an early appointment that compression would be of benefit.
” Source location Alan William Rowland Smith · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of the need for prompt referral to District Nursing services
Wider context from the report “3. The inquest was told that as well as referral to vascular services it was important that GPs understood that District Nurses were a resource that should be utilised with prompt referrals . This could be challenging as the District Nursing Service was under huge pressure due to demand. However, they were well used to recognising high risk patients and clearer referrals for GPs around when to refer would ensure that their expertise would be available at an early stage. Management of any case such as Mr Smith’s would of necessity involve the District Nursing Team as compression bandaging was the most effective treatment to prevent a critical situation such as Mr Smith’s arising and the District Nurses were best placed to provide this. In Mr Smith’s case the referral for District Nursing input was not until a very late stage even though the GP had identified at an early appointment that compression would be of benefit.
” Source location Alan William Rowland Smith · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a Masterclass on timely vascular and District Nursing referrals, including required referral information and examples of good referrals.
Verbatim wording from the response “In light of the findings in this case, a Masterclass learning event will be delivered in September 2024 to include advice and guidance in relation to the circumstances in which to refer and the information required within a referral to ensure timely triage and progression to care under the vascular surgery team as appropriate.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice considers that Mr Smith’s leg-swelling management, compression hosiery and District Nursing referral were clinically appropriate.
Verbatim wording from the response “Following the inquest and the issuing of the Regulation 28 in this case, the GP partners have undertaken a full review of Mr Smith’s journey of care, focusing on the timing of referrals into specialist services including referrals to the vascular surgery team. The practice maintain that the management of Mr Smith’s leg swelling was appropriate.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation District Nursing referrals are triaged and prioritised by clinical need, with enquiries from GPs welcomed and visits arranged where indicated.
Verbatim wording from the response “Regardless of the level of demand on the District Nursing (DN) Team, all referrals are triaged and prioritised appropriately so that patients are seen in order of clinical need. The service confirm that they welcome enquiries from their GP colleagues and where an enquiry indicates the potential need for a DN visit this is arranged.” Source location Response from Greater Manchester Integrated Care
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9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure to make post-discharge referrals for patients needing district nursing care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission City Health Care Partnership CIC Hull University Teaching Hospitals NHS Trust St Andrews Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Hull University Teaching Hospitals NHS Trust
Finalize and roll out an electronic nursing discharge pro forma prompting community-nursing referral consideration and recording referral recipients.
View source
Hull University Teaching Hospitals NHS Trust
Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
View source
City Health Care Partnership CIC
Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
View source
City Health Care Partnership CIC
Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
View source
Care Quality Commission
Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
View source
St Andrews Surgery
Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.
View source See 3 more actions
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AI-generated summary
Linda Heath · 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 Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” Source location Linda Heath · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalize and roll out an electronic nursing discharge pro forma prompting community-nursing referral consideration and recording referral recipients.
Verbatim wording from the response “The Trust confirms that it has developed a pro forma to be utilised by nursing staff in relation to each and every discharge of an in-patient. This pro forma will be used when nurses are planning for a patient’s discharge, and it will identify and highlight a number of matters that need to be considered and addressed at the point of discharge. The pro forma is still being finalised, this work is expected to conclude within the next two weeks – because it is an electronic system, the Trust’s digital team has been involved in updating it. That said a number of words are already using the document in paper form but this will be rolled out across the Trust very shortly.” Source location Response from HUTH
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
Verbatim wording from the response “In relation to the immediate discharge summary this is a document completed by medical staff, and is intended to be a summary of the medical care. There are ongoing discussions about the level of information that should be included within the form, as it is important it does not become too lengthy, but the Trust is of the view that in order to prevent the problem that occurred in Linda’s case, the issue to be addressed is ensuring that appropriate referrals are made in the first place, by the Trust at the point of discharge. In Linda’s case if the discharge summary had noted the need for community nursing referral it is true that it is possible the GP could have followed this up, but in fairness it would not be the GP’s responsibility to do that. In Linda’s case she proactively sought input from her GP and their involvement was discussed at the Inquest.” Source location Response from HUTH
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
Verbatim wording from the response “• Internally CHCP services can send SystmOne to SystmOne referrals, (SystmOne is CHCP main Electronic Care Record (ECR) system). CHCP is currently exploring options to enable external SystmOne users to also send SystmOne to SystmOne referrals.” Source location Response from City Healthcare Partnership Hull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
Verbatim wording from the response “• CHCP regularly shares updates in relation to the referral criteria, services offered and how to refer with GPs and other HCP organisations including Secondary Care, and GPs and HCP organisations also have access to the Directory of Services (DoS) via www.directoryofservices.nhs.uk & NHS Service Finder via www.servicefinder.nhs.uk” Source location Response from City Healthcare Partnership Hull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Verbatim wording from the response “A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.
Verbatim wording from the response “To address concerns regarding the lack of referrals to the district nursing team and other issues raised, the following measures have been discussed with the practice team and implemented to prevent future occurrences:” Source location Response from GP Surgery
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.
Verbatim wording from the response “Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest in relation to points 1 and 4. Points 2 and 3 relate to primary care.” Source location Response from HUTH
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Feedback on the concerns cannot be provided because no referral was made to Community Nursing, and the referral hub manages all CHCP referrals.
Verbatim wording from the response “City Health Care Partnership (CHCP) is unable to provide any feedback in relation to the above concerns, as there was no referral made to CHCP Community Nursing by Hull University Teaching Hospital (HUTH) or St Andrew’s Surgery Hull. CHCP has a 24-hour Care Co-ordination Hub, which manages all referrals into CHCP.” Source location Response from City Healthcare Partnership Hull
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.
Verbatim wording from the response “During the inspection process we routinely review correspondence, tasks and referrals. We will use the regulation 28 report to remind colleagues of the importance of this process.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Verbatim wording from the response “A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response.” Source location Response from CQC
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15 Nov 2022 Ronald Alfred KELLY · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to action appropriate referrals for district nurse visits and assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Ronald Alfred KELLY · 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
Ronald Alfred KELLY, aged 91, was found hanging on 19 September 2022 after recently being discharged from hospital and struggling to cope. The concerns included his discharge following surgery without a care package or follow-up, a rejected district nurse referral that was not actioned, and the apparent absence of a system for automatically following up patients discharged home who may need support and care. The inquest concluded that Mr Kelly died from suicide.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to action appropriate referrals for district nurse visits and assessments
Wider context from the report “1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping.
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first” . The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up.
” Source location Ronald Alfred KELLY · Prevention of Future Deaths report
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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 referral process with staff to identify learning.
Verbatim wording from the response “Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.” Source location Response from Central and North West London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the Standard Operating Procedure to require tighter follow-up when additional referral information is requested.
Verbatim wording from the response “Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.” Source location Response from Central and North West London NHS Foundation Trust
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7 May 2021 Macaulay WILSON · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to use specific language distinguishing catheter change from catheter care in requests View source
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Macaulay WILSON · 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
Macaulay Wilson had a long-term indwelling urinary catheter that was not changed for almost a year, despite the catheter reportedly needing replacement every 12 weeks. The inquest determined that the failure to change it caused urosepsis. Concerns included failures by the hospital urology department to risk assess and arrange appropriate catheter changes, district nurses not enquiring about catheter changes, and unclear communication by the GP practice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to use specific language distinguishing catheter change from catheter care in requests
Wider context from the report “The Homerton University Hospital urology clinical nurse specialist wrote to your practice on 18 February 2019, and included within the letter a request that you arrange for district nurses to change Mr Wilson’s indwelling catheter in 12 weeks.
A doctor from your practice did consider the letter, did action it and did write to the district nurses, but did not include a specific request for catheter change (as opposed to catheter care, which does not include change of the catheter) .
It seems that your doctors’ use of language in this situation would benefit from further consideration .
” Source location Macaulay WILSON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight instructions for other clinical teams and send the original correspondence with onward referrals.
Verbatim wording from the response “Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.” Source location 2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the revised processes to the team and incorporate them into the induction programme.
Verbatim wording from the response “We have communicated the above to all members of the team including the person responsible for coding incoming patient related correspondence and these processes have been incorporated into our induction program. We have informed our local medicines management team about this case to ensure they can disseminate this risk within their monthly newsletter so that other practices can ensure a similar event does not occur. We have reported the incident via the National Reporting and Learning System and have informed the CCG. We are amending the City and Hackney wide EMIS template which is used when visiting housebound and vulnerable patients to include parameters such as catheters and catheter change as well as other issues which may increase patient risk such as pressure sores and falls.” Source location 2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
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3 Feb 2021 CHRISTOPHER SMITH · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to make district nurse referrals for specialist wound care View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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CHRISTOPHER SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make district nurse referrals for specialist wound care
Wider context from the report “(5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse referral was made to ensure that Mr Smith’s leg ulcers were treated.
” Source location CHRISTOPHER SMITH · Prevention of Future Deaths report
Open source report
21 Feb 2020 Anita Loi · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to respond to community referrals for wound management View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Central London Community Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Central London Community Healthcare NHS Trust
Implement updated triage procedures requiring checks for other services and coordinated review of referrals received by multiple teams.
View source
Central London Community Healthcare NHS Trust
Improve referral processes from primary care into District Nursing and Tissue Viability Nursing teams.
View source
Central London Community Healthcare NHS Trust
Develop electronic patient-record reminders in EMIS Health to improve referral management and responsiveness.
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Central London Community Healthcare NHS Trust
Establish multidisciplinary review processes for people referred to multiple teams.
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AI-generated summary
Anita Loi · 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
Anita Loi, who had Type 1 diabetes, suffered a burn to her left leg in April 2019 that developed into an infected wound. Despite repeated referrals, the community nursing teams did not attend to management of the wound, and she later suffered cardiac arrest and died in hospital on 1 July 2019. The principal concerns were the lack of response to referrals and whether appropriate referral policies and procedures were in place.
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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 respond to community referrals for wound management
Wider context from the report “(1) The Tissue Viability Nurse and District Nurses are a part of the same community team but no steps had been taken to attend to the management of Anita Loi’s leg wound despite repeated referrals by the GP and a call to the community team by the family .
” Source location Anita Loi · Prevention of Future Deaths report
Open source report
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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 Implement updated triage procedures requiring checks for other services and coordinated review of referrals received by multiple teams.
Verbatim wording from the response “We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals. The procedure now ensures that Triage nurses check if patients are open to other CLCH services. If the referral received is for more than one service on the same day the triage nurse must make contact with that other service to initiate joint working and ensure that visits are allocated appropriately. When a referral is received by more than one service, a meeting is held to ensure that the patient’s referral, clinical history is reviewed jointly and a plan of action on how best to manage the patient’s care is determined.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
Open published response
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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 Improve referral processes from primary care into District Nursing and Tissue Viability Nursing teams.
Verbatim wording from the response “1. We have undertaken an urgent review and are improving the referral processes from primary care into DN & TVN teams.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
Open published response
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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 Develop electronic patient-record reminders in EMIS Health to improve referral management and responsiveness.
Verbatim wording from the response “2. We will commence work on our electronic patient record system to strengthen the reminder capability in EMIS Health, (Egton Medical Information Systems), to ensure that referrals are effectively managed and responsiveness is maximised.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
Open published response
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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 Establish multidisciplinary review processes for people referred to multiple teams.
Verbatim wording from the response “5. We will establish clear processes to be in place to review jointly as part of an MDT all people referred who are know to multiple teams to ensure timely joined up responsiveness.” Source location 2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf
Open published response
17 May 2019 Mellin Beard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to provide timely referrals for discharged patients requiring community nursing services View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Tameside and Glossop Integrated Care NHS Foundation Trust
Move all Trust referrals to District Nurses onto an electronic portal.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Tighten referral processes while migrating from fax machines to electronic communication systems.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Reinforce clinical incident reporting for missed referrals to support investigation, learning and training.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Track missed-referral incidents and escalate identified trends or themes through divisional meetings for timely action.
View source See 1 more action
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AI-generated summary
Mellin Beard · 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
Mellin Beard, who had complex health problems including spinal cord compression and reduced mobility, developed pressure sores that later deteriorated despite care. He died on 16 October 2018 from left ventricular failure due to ischaemic and hypertensive heart disease, with infected pressure sores among the contributing health problems. Concerns included delays in referrals for community nursing after hospital discharge and significant reliance on agency nurses.
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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 timely referrals for discharged patients requiring community nursing services
Wider context from the report “1. A member of the Trust’s community nursing team gave evidence to the effect that it was ‘common’ not to receive timely referrals in respect of patients who were discharged from hospital and required community nursing services . Whilst it was apparent from the evidence before the court as a whole that this concern does not relate solely to patients who have been receiving in-patient care at Tameside General Hospital, and that some improvements have been made with the introduction of an e-discharge system, it is a matter of particular concern that this problem continues to subsist at the Trust in particular due to the integrated care model as between acute and community services the organisation purports to espouse;
” Source location Mellin Beard · Prevention of Future Deaths report
Open source report
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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 Move all Trust referrals to District Nurses onto an electronic portal.
Verbatim wording from the response “As part of our investigation into your concern, discussions have been held with the Head of Nursing, Community Adults, the Service Director and Lead Nurses of the Trust's Intermediate Tier Services, and the Team Lead for SPOC in relation to ongoing improvements in the District Nursing referral process. I am happy to inform you that we will be moving onto an electronic portal for all referrals to District Nurses made within the Trust. Once this has been running for a while, we will investigate the potential for non-Trust agencies to also use this portal for referrals, as we receive a high number of referrals from care homes.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
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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 Tighten referral processes while migrating from fax machines to electronic communication systems.
Verbatim wording from the response “Given we are still working towards moving onto the electronic system, we have taken steps to tighten our processes in the meantime and are currently working through our strategy for the removal of all fax machines and the migration to electronic communication systems.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
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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 Reinforce clinical incident reporting for missed referrals to support investigation, learning and training.
Verbatim wording from the response “Further, whenever a missed referral is identified by any member of staff, they have a responsibility to raise a clinical incident report so that the matter can be investigated. District Nurses have continuously reinforced the importance of a robust incident-reporting culture so as to ensure further incidents can be prevented and appropriate learning and training can take place to keep patients safe.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
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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 Track missed-referral incidents and escalate identified trends or themes through divisional meetings for timely action.
Verbatim wording from the response “In addition to reviewing individual incidents, which are raised when a missed referral is identified, these incidents are tracked by relevant services and any trends or themes are looked for to ensure these are quickly identified and addressed. Any trends or themes that are identified are highlighted to the relevant divisions in their regular divisional meetings so that appropriate steps can be taken to address them in a timely manner.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
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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 Missed referrals are not considered common, based on team experience, incident review and evidence from the referral service.
Verbatim wording from the response “As mentioned above, we have made enquiries to assist you in understanding more fully if missed referrals are ‘common’. A meeting took place at the beginning of June with the Trust's entire group of District Nursing Team Leads and their Matron at which a discussion was had regarding the regularity of missed referrals. The consensus was very much that this was not a ‘common’ or regular occurrence from their professional experience. A review of all incidents detailing a missed referral from March 2018 to March 2019 was completed. This review found that a total of eight missed referrals were identified in this twelve month period. A rate 0.67 missed referrals per month is not considered to be ‘common’ by the Trust. Enquiries were also made with the Trust's Single Point of Contact [SPOC], which is a Trust service that receives and triages all referrals to District Nurses trust-wide.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
Concerns raised 1
Lack of a procedure to ensure that referrals are received and actioned View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Carol Ann Harvey · 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 Harvey, aged seventy, was discharged from hospital with care planned at home, but no carers attended after a referral message was left without confirmation that it had been received. She was found the following morning drowsy, vomiting and having suffered significant blood loss, and died in hospital on 9 April 2016 following a paracetamol overdose and a pre-existing cardiac condition. The principal concerns were the lack of a procedure to confirm that referrals had been received and actioned, and delay in implementing a safe hospital discharge procedure.
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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 Lack of a procedure to ensure that referrals are received and actioned
Wider context from the report “(a) That although a referral had been made to the District Nurse Team, there is no procedure in place to ensure that such a referral has been both received and actioned .
” Source location Carol Ann Harvey · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.