Recurring concern

Unreliable hospital discharge processes

First to latest report 30 Jan 2013 — 10 Jun 2026

Reports that mention this concern
273
Times this concern has been raised
406
Stated actions linked to this concern
524

What this concern includes

Includes failures in hospital discharge planning, readiness decisions, multidisciplinary or receiving-service coordination, safety planning, execution and directly required follow-up.

What is not included
  • Inter-hospital patient transfer where no discharge from hospital care occurs
  • Failures in treatment after a safe and complete discharge
  • Generic care coordination unrelated to a hospital discharge process
  • Delays in admission or movement within hospital before discharge is being planned

Reports and published responses 273 reports

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

  1. Surrey

    AI-generated summary

    Melanie Jane ELMS · 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

    Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to follow and maintain an adequate post-discharge care package

    Wider context from the report

    “1. The care package arranged for Melanie following discharge from lengthy in-patient admission was not followed and was altered to something which the treating doctor did not consider adequate. ”

    Source location

    Melanie Jane ELMS · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  2. West Yorkshire Eastern

    AI-generated summary

    Neil Peter Bastock · 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

    Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

    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 heed family warnings about a patient’s fitness for discharge

    Wider context from the report

    “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”

    Source location

    Neil Peter Bastock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 establish alternative accommodation and transition arrangements before discharge consideration

    Wider context from the report

    “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”

    Source location

    Neil Peter Bastock · 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

    Ensure Triangle of Care principles are enacted consistently for service users and family members.

    Verbatim wording from the response

    “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 4 November 2021

    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

    Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.

    Verbatim wording from the response

    “e. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 4 November 2021

    Open published response

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Kirsty Marie Doodes · 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

    Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.

    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 meaningfully involve families and carers in the discharge process

    Wider context from the report

    “iii) Lack of involvement of family/carer in discharge process The Trust’s own discharge policy states: 3. Principles The decision to discharge someone from hospital must be in keeping with the Care Programme Approach (CPA), (DH 1991, 2008) and governed by the following principles: The patient, carer and / or advocate, must be actively involved in all aspects of the discharge plan, where practicable. Arrangements for discharge should be negotiated with everyone likely to be concerned with the service user’s aftercare. ████████ was Kirsty’s carer. He had not been ‘actively involved in all aspects of the discharge plan.’ He had a phone call to come and collect her and on arriving at the hospital he found her bag to be packed. He did not feel as though he was given any choice. I acknowledged at inquest that there were extenuating circumstances in that Kirsty’s discharge coincided with the first national lockdown during the COVID pandemic. Nevertheless, I think it is appropriate to bring to your attention whether there is a need to remind clinicians to involve families and carers in a meaningful way during the discharge process. ”

    Source location

    Kirsty Marie Doodes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 the rationale for discharge safety decisions

    Wider context from the report

    “i) Insufficiency of note-keeping. ii) ████████ The note made by Dr ████████ in the RiO records was described by an independent expert, Dr ████████, as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that Kirsty was safe to go home. In a context where she has, over a very recent period, attempted to ████████ on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out. Of perhaps more significance is that there was nothing in the note to assist clinicians with understanding how the future care plan was to be organised. That was in a context where a national lockdown was imminent. Given the unprecedented circumstances, it seems apparent to me that there was all the more reason to provide detail in this regard. The fact it was not set out, it seems to me, implies that there was doubt on the part of Dr ████████ about the plan to continue treating Kirsty was to be organised. My fear is that this simply passed the burden of the management of the risk to ████████. This reached an entirely foreseeable crisis in the early hours of 23 March. Kirsty had deteriorated to the point she was described as very suicidal. ████████ was exhausted from his desperate efforts to keep his safe. He rang the ward for assistance. There was no one available to help him. ████████ was advised to call the emergency services. He rang the police who told him to ring the ambulance service who told him to ring the CMHT in the morning. This should not have happened. A detailed plan with how to manage an acute deterioration could have prevented it. At the time, Doctor ████████ was effectively carrying the burden of two consultant psychiatrists in that Dr ████████ was away from work. I indicated at inquest that if this was due to under-resourcing of the Trust, I would write to those responsible for funding. I was advised that, in fact, the problem may be due to a scarcity of consultant psychiatrists nationally. I would be grateful if you could please let me know the position. ”

    Source location

    Kirsty Marie Doodes · 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 Trust’s mental health acute ward discharge policy and prioritise vital discharge steps and multidisciplinary roles and responsibilities.

    Verbatim wording from the response

    “With the above factors in mind, we have identified learning for us in that we need to support our clinicians to improve the discharge process and we therefore intend to review the Trust’s mental health acute ward discharge policy to support this.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    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

    Work on reducing hospital length of stay towards the national average while following best evidence and allowing families time to understand discharge decisions.

    Verbatim wording from the response

    “Additionally, we are committed to working on the length of stay in our hospitals in an attempt to ensure that it is closer to the national average whilst continuing to work in line with best evidence such as the NICE Guidelines. This will often (and perhaps more frequently) mean that families and carers may find the rationale for discharge contrary to their wishes and/or counterintuitive. For this reason, time to enable families to work through, question and hopefully accept this will need to be prioritised as although Mr Doodes was involved in his wife’s discharge planning, we recognise that he did not feel as supportive of the plan as we would have liked.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review accepted clinical documentation standards to maximise clinicians’ time for compassionate, person-centred care and discussions with families and carers.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    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

    Consider including a concise template for documenting inpatient discharge decisions in the discharge policy review.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    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

    Finite services and limited clinical time prevent consistently prioritising comprehensive documentation alongside direct patient and family care.

    Verbatim wording from the response

    “Sadly, services are finite and we have to balance the extent to which we prioritise the most comprehensive documentation, against the time available for clinical care with patients and their families. As part of our plan to improve mental health services we will be reviewing our accepted documentation standards, with the aim of supporting and directing our clinicians to spend the maximum amount of time providing compassionate, person-centred care, while minimising what may ultimately be, unhelpfully defensive documentation. This approach will also allow clinicians as much time as possible to have difficult discussions with families and carers, for example around discharges from hospital. As such, consideration will be given as part of the review of the discharge policy (described above) to include a template for documenting inpatient discharge decisions.”

    Source location

    2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 18 October 2021

    Open published response

  4. Manchester City

    AI-generated summary

    Jude Daryl Lloyd · 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

    Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

    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 comprehensive diabetes monitoring and management risk review and care planning before discharge

    Wider context from the report

    “a. No thorough comprehensive risk review and care plan was formulated in relation to his Diabetes monitoring and management prior to his discharge from the inpatient unit. This was not recognised before he left the ward and it was not discovered by the CMHT when they took over his care. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.

    Verbatim wording from the response

    “Going forward the Trust physical health care group will reinstate a Diabetes workstream to continue to improve the management of people with diabetes across the Trust. We will ensure that the Diabetes workstream have oversight of compliance with training about diabetes management and are involved in the management and risk analysis incidents around diabetes care. We intend to make the care of someone with diabetes as one of our main quality improvement care projects in the organisation that will be led by the physical health care group who will act as the lead for this. This will involve further enhancing the connections and communication with primary care and will involve the new primary healthcare practitioners, which are new joint posts working across the new primary care networks and GMMH.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 13 October 2021

    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

    Address coordination of diabetes management at discharge through the diabetes steering group.

    Verbatim wording from the response

    “The HbA1c is a measurement of control of blood glucose (glycaemic control) over the weeks prior to the test being taken so the HbA1c of 135 suggested extremely poor glycaemic control in the community whilst Mr Lloyd was under the care of his GP prior to admission. We agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to any improvement in glycaemic control and was not a robust plan to manage this. We will address discharge diabetes management coordination via the diabetes steering group.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    Open published response

  5. Manchester City

    AI-generated summary

    Antony Declan Schofield · 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

    Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

    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 comprehensive pre-discharge risk review by staff with detailed knowledge of the patient

    Wider context from the report

    “1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”

    Source location

    Antony Declan Schofield · 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 inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.

    Verbatim wording from the response

    “During the period under review the Manchester services had recently changed to a new patient clinical record system, Paris, and were in the process of implementing the associated documents such as the Star V2 Risk Assessment which meant that there were some gaps in the services adhering to the Trust Policy. The Standard Operating Procedures (SOP) for both the Inpatient wards and the HBTT have been updated to reflect the Trust Clinical Risk Policy and when staff should be completing a risk assessment. This includes on entry and discharge from a service as well as identified periods in between and in response to any changes to a person’s risks. The Safire SOP clearly outlines that a patient’s risk assessment should be reviewed and updated prior to discharge from the ward and that a crisis plan should be in place.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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 discharge checklist requiring review and updating of the risk assessment before discharge.

    Verbatim wording from the response

    “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.

    Verbatim wording from the response

    “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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

    Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.

    Verbatim wording from the response

    “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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

    Risk was explored and assessments were completed before discharge, although the assessment was not always updated.

    Verbatim wording from the response

    “Mr Schofield was admitted to Safire Ward on 8 August 2019. He was discharged from Safire Ward on 20 August 2019. The GMMH risk assessment tool, Star V2 Risk Assessment was completed by Safire staff during Mr Schofield’s inpatient admission on 9, 11 and 19 August 2019. As the Trust’s Investigation Report identified that staff explored risk with Mr Schofield over the night of the 18th and the morning of 19 August 2019 although did not update the Star V2 Risk Assessment. During the review of his risk Mr Schofield confirmed that he had no thoughts of wanting to ████████ despite these matters being explored. When Mr Schofield was discharged to the HBTT his risk was explored by staff with him although the Star V2 Risk Assessment was not updated. GMMH Trust Clinical Risk Policy clearly sets out when a risk assessment should be undertaken.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 1 · response
    Published 5 October 2021

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Cherry Rosemary Dunn · 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

    Cherry Rosemary Dunn died after an acute episode at Kirby Ward on 5 November 2018, with the inquest recording pulmonary embolism, deep vein thrombosis and immobility as causes of death. Concerns included bilateral leg swelling not prompting sufficient consideration of deep vein thrombosis, ambiguity in VTE risk assessments, and confusing hospital discharge letters that affected decisions about prophylactic anticoagulation.

    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 of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly

    Wider context from the report

    “• Hospital discharge letters The discharge letter used when Mrs Dunn was transferred from one hospital setting to another (attached) was confusing. The doctor at the receiving hospital read it to mean that prophylactic anticoagulation was not required and therefore the doctor was persuaded in part by this even though the risk assessment that was completed had a positive result. The University Hospitals of Leicester NHS Trust have now revised their discharge letter (attached) which more clearly reflects NICE Guidance and removes the previous confusion. However, there is a concern that the original discharge letter is used in other Trusts and therefore the confusion remains in other areas with the risk of what happened in this case happening elsewhere. ”

    Source location

    Cherry Rosemary Dunn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. North East Kent

    AI-generated summary

    Hadley John Savory · 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

    Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.

    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 evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs

    Wider context from the report

    “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”

    Source location

    Hadley John Savory · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 evidence of multi-agency planning meetings before discharge

    Wider context from the report

    “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”

    Source location

    Hadley John Savory · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. North East Kent

    AI-generated summary

    Hadley John Savory · 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

    Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.

    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 multi-agency procedures for safe discharge of patients with concurrent care needs

    Wider context from the report

    “(1) There was no evidence of a multi Agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”

    Source location

    Hadley John Savory · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 hold multi-agency discharge planning meetings

    Wider context from the report

    “(1) There was no evidence of a multi Agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”

    Source location

    Hadley John Savory · 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 hospital discharge policy and operating model, supported by discharge guidance action cards defining responsibilities for key roles.

    Verbatim wording from the response

    “Following the sad death of Mr Savory and due to changes to practice following COVID, KCC updated its ‘Hospital Discharge Service Policy and Operating Model’. This new policy and operating model is designed to support the full implementation of discharge, and to aide this a set of discharge guidance action cards has been developed to summarise responsibilities for key roles within the hospital discharge process.”

    Source location

    Response-from-Kent-County-Council
    Page 2 · response
    Published 19 August 2021

    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

    Establish named KCC hospital discharge leads to attend discharge management meetings and provide social care advice, guidance and escalation.

    Verbatim wording from the response

    “There will be named leads for each Acute and Community Hospital which will be the KCC Short Term Pathways (STP) Team Manager, supported by the Senior Practitioner and Social Care Discharge Co-Ordinator in the first instance with escalation if required to the area Service Manager within STP. The expectation is that these named leads will attend discharge management meetings and together with health colleagues will provide social care advice and information, guidance as well as influencing and supporting the decision making process of the Multi-Disciplinary Teams (MDTs) for safe discharges of people via Discharge to Assess.”

    Source location

    Response-from-Kent-County-Council
    Page 3 · response
    Published 19 August 2021

    Open published response

  9. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    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 clear, accurate and complete discharge advice

    Wider context from the report

    “4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate”. On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020. ”

    Source location

    Ben Buster KING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind the Emergency Department team to confirm that patients, relatives and carers understand discharge advice and safety-netting instructions.

    Verbatim wording from the response

    “• the entire ED team have been reminded to check with carers, relatives and patients that the discharge advice is clear and understood so that people know what to do if the patient’s condition does not improve;”

    Source location

    2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
    Page 3 · response
    Published 23 July 2021

    Open published response

  10. Manchester South

    AI-generated summary

    Clive Edward Rivers · 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

    Clive Edward Rivers was admitted to hospital after a fall, contracted Covid-19 while awaiting discharge, and died at home after being discharged to sheltered accommodation with a care package and a requirement to isolate. Concerns included his not being vaccinated while an inpatient, delays in discharge planning during which he contracted Covid-19, and an assessment framework that did not appear to account for his vulnerability to rapid deterioration while isolating at home.

    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 of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline

    Wider context from the report

    “3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19. ”

    Source location

    Clive Edward Rivers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in discharge planning and Right to Reside assessment

    Wider context from the report

    “2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19. ”

    Source location

    Clive Edward Rivers · Prevention of Future Deaths report
    Page 2 · 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