Recurring concern

Unreliable hospital discharge processes

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First reported 30 Jan 2013•Latest report 10 Jun 2026

Definition

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.

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: 273
Individual concerns: 406
Date range: 2013–2026
Stated actions: 524

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care48

NHS England20

University Hospitals Sussex NHS Foundation Trust9

Essex Partnership University NHS Foundation Trust8

Manchester University NHS Foundation Trust8

Barts Health NHS Trust7

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

NHS Greater Manchester Integrated Care Board6

Tameside and Glossop Integrated Care NHS Foundation Trust6

Betsi Cadwaladr University LHB5

Kent and Medway Mental Health NHS Trust5

Pennine Care NHS Foundation Trust5

Royal London Hospital5

Stockport NHS Foundation Trust5

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

28 Nov2017
Staffordshire South
Concerns raised1
1. Failure to move medically fit patients from hospital into suitable social placements
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Edna Marina Collett · 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

Edna Marina Collett was admitted to hospital on 10 March 2017 and remained there until her death on 19 May 2017. The report identified delays in arranging a suitable community care package, meaning she stayed in hospital for more than two months despite being fit for discharge, and raised concerns about improving the system for moving patients on from hospital.

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 move medically fit patients from hospital into suitable social placements
Wider context from the report
“Mrs Collett was in hospital for more than 2 months. For the great majority of that time she did not need to be in hospital and the reason for her being there was that a suitable social placement could not be found for her. You will be well aware of the pressure on hospital beds. Although it may to some extent be out of your control I wonder if you could please look at the existing system to see if there can be improvements in moving patients on from hospital when they are fit to go. ”
Source location
Edna Marina Collett · Prevention of Future Deaths report
Page 1 · concerns
Open source report
31 Oct2017
North Wales (East and Central)
Concerns raised1
1. Lack of clarity about senior paediatric assessment requirements before discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Alter parent discharge information to state explicitly that parents may request escalation for a consultant review.
  Stated by Betsi Cadwaladr University LHBStated planned
AI-generated summary

Kate Louise Pierce · 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

Kate Louise Pierce became unwell on 29 March 2006 and was discharged from hospital after being diagnosed with viral tonsillitis. She returned approximately 36 hours later in a deteriorated condition, was diagnosed with pneumococcal meningitis, and later died in Florida on 19 March 2013 after suffering brain damage and other health conditions. The principal concerns were uncertainty about when a sick child should receive senior paediatric assessment before discharge, and a lack of clearly defined and consistently applied processes for identifying and acting on learning opportunities after adverse events or re-presentation.

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 clarity about senior paediatric assessment requirements before discharge
Wider context from the report
“(1) There remains uncertainty about the circumstances in which a sick child should be seen by a senior Paediatrician (Registrar or above) prior to discharge. During the hearing I was shown a document headed ‘Guidance to Paediatric Junior Doctors on Discharge [sic] Children From Assessment Unit’, which I was given to understand reflects current practice and represents an improvement on the position in 2006. The information in the letter of 4 October 2017 is broadly consistent with it. Both documents are silent as to whether a parental request for a second opinion should automatically lead to an examination of the child by the senior doctor, as was opined in court, where the importance and significance of parents’ views were noted. . I am concerned that a lack of clarity about the Health Board’s expectations in this respect may continue to allow for the possibility of a child being discharged without a sufficient (and sufficiently senior) assessment having been made. ”
Source location
Kate Louise Pierce · 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
Alter parent discharge information to state explicitly that parents may request escalation for a consultant review.

Verbatim wording from the response
“Whilst we are confident that the culture of the department is such that a parental request or indeed concern from any member of staff would lead to a consultant review, we have taken the decision to alter the parent discharge information to explicitly state this.”

Source location
2017-0312-Response-by-University-Health-Board
Page 1 · response
Published 28 November 2017
Open published response
5 Oct2017
North West Wales
Concerns raised2
1. Discharge decisions made without involvement of a clinician responsible for the patient's care
2. Delay in sending discharge information to the GP
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Simon Willans · 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

Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.

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
Discharge decisions made without involvement of a clinician responsible for the patient's care
Wider context from the report
“(3) Mr Willans appears to have been discharged by a Nurse Practioner ████████ who had no involvement in the care of Mr Willans. ████████, or any other doctor does not appear to have been involved in the discharge of Mr Willans. Nurse Practitioner Jones adds another diagnosis to the GP letter over and above that of her colleague despite never seeing the patient. ”
Source location
Simon Willans · 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
Delay in sending discharge information to the GP
Wider context from the report
“(4) There is insufficient safety netting for this patient. He was not told what to do in the event of a worsening of his condition. The letter to the GP was faxed the day after discharge by which time he had died ”
Source location
Simon Willans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Sep2017
Black Country
Concerns raised1
1. Failure to incorporate relevant information into discharge assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Melvin James and Anne-Marie James · 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

Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate relevant information into discharge assessment
Wider context from the report
“1. Evidence emerged during the inquest that by the time of his discharge on Friday 10th February 2017 and as far as the Hospital were concerned, they recorded he showed no evidence of mental illness. However, the Clinician who dealt with the discharge confirmed that he wasn’t aware of the conversation he had with his brother on the way to Wolverhampton where Mr James was still talking about his delusions including creatures transforming. Significantly, during the inquest he accepted, had he known this he would have formed the view that he was still unwell. ”
Source location
Melvin James and Anne-Marie James · Prevention of Future Deaths report
Page 3 · concerns
Open source report
8 Sep2017
Manchester West
Concerns raised1
1. Lack of a protocol for patients self-discharging from hospital without necessary medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Terence Ryan · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.

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 a protocol for patients self-discharging from hospital without necessary medication
Wider context from the report
“ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. ”
Source location
Terence Ryan · 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
Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.

Verbatim wording from the response
“I have been informed that a bulletin with the key requirements of the Policy for Self-Discharge Against Medical Advice has been prepared for both clinicians and for the nursing staff to heighten awareness of the policy and ensure compliance. This information has been and will be shared/communicated in the following ways:”

Source location
2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
Page 3 · response
Published 6 October 2017
Open published response
8 Sep2017
Manchester West
Concerns raised1
1. Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update outpatient appointment cards with advice to contact NHS 111 or a GP if the patient’s condition deteriorates.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated planned
AI-generated summary

Patricia Forshaw · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.

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
Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards
Wider context from the report
“i. The telephone number on the card given to the deceased when she was discharged from the Hospital related to appointments only but the purpose of the number is ambiguous and when the deceased’s husband telephoned the number on the card in the early hours of the 20th October 2016 he believed he was speaking to the Emergency Department, particularly in view of the fact that he was given advice to give paracetamol to the deceased. Evidence was given at the Inquest that the appointment card was the only documentation given to the deceased when she was discharged and the card does not have any information as to the action to be taken if there is a deterioration in a patient’s condition after discharge. The evidence given by ████████ a Consultant in Emergency Medicine at the Hospital was that if there is a deterioration in condition the patient should not be given treatment advice by telephone and the patient should be advised to telephone 111 or return to the Hospital but ████████ accepted that there is no reference to such action on the card. ”
Source location
Patricia Forshaw · 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
Update outpatient appointment cards with advice to contact NHS 111 or a GP if the patient’s condition deteriorates.

Verbatim wording from the response
“information to be ambiguous. I am aware that the Trust’s outpatient appointment card is to be updated to include advice for patients to contact NHS 111 or their GP if their condition deteriorates.”

Source location
2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
Page 3 · response
Published 2 November 2017
Open published response
10 Aug2017
Mid Kent and Medway
Concerns raised1
1. Failure to provide cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Brief Emergency Department and acute assessment staff on paracetamol and ibuprofen safety advice for overdose patients.
  Stated by Medway NHS Foundation TrustStated planned
2. Action
  Discuss overdose medication safety advice in Emergency Department daily safety huddles.
  Stated by Medway NHS Foundation TrustStated completed
3. Action
  Require staff to document discharge advice given to overdose patients in medical notes.
  Stated by Medway NHS Foundation TrustStated completed
1. Action
  Conduct monthly audits of documented overdose medication advice until practice is assured to be embedded and sustained.
  Stated by Medway NHS Foundation TrustStated planned
2. Action
  Develop an information leaflet explaining paracetamol overdose and medication precautions.
  Stated by Medway NHS Foundation TrustStated completed
3. Action
  Ratify, print and distribute the overdose information leaflet through Emergency Department discharge planning, with documented explanation and subsequent audit.
  Stated by Medway NHS Foundation TrustStated planned
4. Action
  Require nurse-in-charge review of every overdose patient before transfer or discharge, incorporating the requirement into the revised operating framework.
  Stated by Medway NHS Foundation TrustStated completed
AI-generated summary

Claire Joan Elizabeth MEDHURST · 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

Claire Medhurst was admitted after a polypharmacy overdose, was discharged after treatment, and was readmitted with abdominal pain and severe liver abnormalities. Her acute liver failure was not recognised or treated for about six hours before she deteriorated and died on 24 February 2017. Concerns included the lack of cautionary advice about further use of paracetamol or ibuprofen at discharge and the failure of the laboratory to alert clinicians to abnormal results and toxic paracetamol levels.

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 cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge
Wider context from the report
“(1) The discharge process on 25th January 2017 did not include any cautionary advice as to the further use of medications such as paracetamol or ibuprofen as an analgesic particularly when Claire Medhurst had been experiencing headaches shortly before discharge and had been prescribed ibuprofen ”
Source location
Claire Joan Elizabeth MEDHURST · 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
Brief Emergency Department and acute assessment staff on paracetamol and ibuprofen safety advice for overdose patients.

Verbatim wording from the response
“1. All key relevant staff will receive feedback via the appropriate staff meeting. These meetings are already scheduled and all clinicians within the Emergency Department and the acute assessment areas will receive the information through the staff briefings. All staff will be given an overview of the case and the importance of providing essential information to patients and their families on the use of drugs containing paracetamol and ibuprofen will be detailed.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss overdose medication safety advice in Emergency Department daily safety huddles.

Verbatim wording from the response
“2. The importance of providing essential information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol upon discharge has been discussed in the Emergency Department daily safety huddles to ensure that all members of staff are aware of the importance of providing such information.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require staff to document discharge advice given to overdose patients in medical notes.

Verbatim wording from the response
“3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct monthly audits of documented overdose medication advice until practice is assured to be embedded and sustained.

Verbatim wording from the response
“3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop an information leaflet explaining paracetamol overdose and medication precautions.

Verbatim wording from the response
“4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ratify, print and distribute the overdose information leaflet through Emergency Department discharge planning, with documented explanation and subsequent audit.

Verbatim wording from the response
“4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require nurse-in-charge review of every overdose patient before transfer or discharge, incorporating the requirement into the revised operating framework.

Verbatim wording from the response
“5. All patients with an overdose must be reviewed by the nurse in charge of the department/acute assessment wards prior to their transfer or discharge. This will ensure that the patients’ medical management and discharge plan has been fully implemented. In the case of paracetamol overdose this has been included in the revised standard operating framework (appendix 3). The Trust adhere to national poisons guidance and access to this is available to all staff working in the ED/acute assessment areas.”

Source location
2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017
Open published response
17 Jul2017
Manchester South
Concerns raised1
1. Delays in dispatching discharge summaries
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Deploy additional resources to clear the discharge-summary backlog and restore timely completion.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
3. Action
  Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Matthew Robert Edwards · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in dispatching discharge summaries
Wider context from the report
“1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result, Matthew Edwards GP was not notified about his period as an in patient. When he attended a subsequent GP appointment, she was unclear about the discharge plan for Mr Edwards and the rationale for it. ”
Source location
Matthew Robert Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deploy additional resources to clear the discharge-summary backlog and restore timely completion.

Verbatim wording from the response
“In order to bring the position back to a baseline from which the Trust could confidently move forwards with new processes, extra resources were brought in to clear a backlog that had regrettably developed with discharge summaries. I wish to assure you that the Trust fully recognises the importance of discharge summaries as a handover of care between different organisations and services involved in the care of a patient. I was disappointed to learn that a backlog had developed due to other organisational pressures and asked my Executive team to take immediate steps to identify the source of the problem and remedy it as swiftly as possible.”

Source location
Matthew-Edwards-Response
Page 1 · response
Published 17 July 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.

Verbatim wording from the response
“I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.”

Source location
Matthew-Edwards-Response
Page 2 · response
Published 17 July 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.

Verbatim wording from the response
“The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from Brendan Ryan, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the Consultant responsible for that episode of care, and this has been reiterated to all consultants. Compliance is being monitored by the Trust's Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made and maintained.”

Source location
Matthew-Edwards-Response
Page 2 · response
Published 17 July 2017
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.

Verbatim wording from the response
“This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.”

Source location
Matthew-Edwards-Response
Page 3 · response
Published 17 July 2017
Open published response
5 Jun2017
Manchester South
Concerns raised1
1. Failure to provide discharge summaries to GPs after emergency department attendance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Deploy additional resource to clear the discharge-summary backlog.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Assign divisional operational leadership for improving discharge-summary completion.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
3. Action
  Reiterate consultants’ responsibility for ensuring every patient receives a discharge summary.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
1. Action
  Monitor discharge-summary compliance through governance, clinical and operational management arrangements.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Develop bespoke software for electronic Emergency Department casualty cards and automated discharge-summary generation.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
3. Action
  Roll out the new electronic Emergency Department casualty-card process from October 2017.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
4. Action
  Introduce dashboard monitoring of discharged Emergency Department patients awaiting discharge summaries and follow-up investigations.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Responsibility for ensuring every patient has a discharge summary rests with the consultant responsible for that episode of care.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustRedirects responsibility
AI-generated summary

Derrick Lawrence Brocklehurst · 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

Derrick Lawrence Brocklehurst was admitted to hospital after being found immobile and incontinent at home, with grade 4 pressure ulcers, and died on 2 December 2016 from a pulmonary embolus. Concerns included missing records of carer visits and the absence of a discharge summary from the hospital to the GP after his A&E attendance.

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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 provide discharge summaries to GPs after emergency department attendance
Wider context from the report
“2. No discharge summary was provided by Tameside General Hospital to the GP after the deceased was seen in A and E. ”
Source location
Derrick Lawrence Brocklehurst · 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
Deploy additional resource to clear the discharge-summary backlog.

Verbatim wording from the response
“In order to bring the position back to a baseline from which the Trust could confidently move forwards with new processes, extra resource was brought in to clear a backlog that had developed with discharge summaries. I wish to assure you that the Trust fully recognises the importance of timely completion of discharge summaries as a handover of care between different organisations and services involved in the care of a patient. I was disappointed to learn that a backlog had developed due to other organisational pressures and asked my executive team to take immediate steps to identify the source of the problem and remedy it as swiftly as possible.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Assign divisional operational leadership for improving discharge-summary completion.

Verbatim wording from the response
“████████ Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from ████████, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the consultant responsible for that episode of care and this has been reiterated to all consultants. Compliance is being monitored by the Trust’s Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reiterate consultants’ responsibility for ensuring every patient receives a discharge summary.

Verbatim wording from the response
“████████ Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from ████████, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the consultant responsible for that episode of care and this has been reiterated to all consultants. Compliance is being monitored by the Trust’s Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor discharge-summary compliance through governance, clinical and operational management arrangements.

Verbatim wording from the response
“████████ Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from ████████, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the consultant responsible for that episode of care and this has been reiterated to all consultants. Compliance is being monitored by the Trust’s Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop bespoke software for electronic Emergency Department casualty cards and automated discharge-summary generation.

Verbatim wording from the response
“I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is planning to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the doctors and nurses in the Emergency Department. The key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Roll out the new electronic Emergency Department casualty-card process from October 2017.

Verbatim wording from the response
“I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is planning to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the doctors and nurses in the Emergency Department. The key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce dashboard monitoring of discharged Emergency Department patients awaiting discharge summaries and follow-up investigations.

Verbatim wording from the response
“The new electronic casualty card system will include a dashboard clearly identifying each and every patient that has been discharged from the Emergency Department but has not yet had a discharge summary completed, allowing the management team to effectively scrutinise compliance. The new process will also allow the Trust to monitor the arrangement of follow up investigations commissioned at the point of discharge from the Emergency Department which will further improve patient safety.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 2 · response
Published 4 August 2017
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for ensuring every patient has a discharge summary rests with the consultant responsible for that episode of care.

Verbatim wording from the response
“████████ Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from ████████, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the consultant responsible for that episode of care and this has been reiterated to all consultants. Compliance is being monitored by the Trust’s Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made.”

Source location
2017-0181-Response-by-Tameside-Glossop-Integrated-Care
Page 1 · response
Published 4 August 2017
Open published response
26 May2017
Wiltshire and Swindon
Concerns raised1
1. Failure to transfer important cognitive assessment information at discharge
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Doreen Helen MILLER · 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

Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

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 transfer important cognitive assessment information at discharge
Wider context from the report
“b) (Great Western Hospital) In considering the evidence when Doreen was discharged from The Great Western Hospital initially on the 21st December 2015, she was sent with a discharge letter and a 4 page Medivo Summary summarising the paramedics’ attendance on the 20th December 2015. Of note that summary did not contain any information that the paramedic had undertaken a 6CIT Cognitive evaluation of Doreen and that she had failed that assessment. One can never guarantee that another document will reflect the information contained in the initial report and therefore a possible way forward could be to ensure in cases where the turnaround through hospital is short that as part of the Discharge Package that it includes a copy of the Paramedic handwritten report that would have been provide to Great Western Hospital when she was admitted. It is however for you to consider how to resolve the concern here that an important bit of information was not provided to the team at Athelston House; ”
Source location
Doreen Helen MILLER · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to move medically fit patients from hospital into suitable social placements

Concerns raised1

Lack of clarity about senior paediatric assessment requirements before discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Discharge decisions made without involvement of a clinician responsible for the patient's care

Delay in sending discharge information to the GP

Concerns raised1

Failure to incorporate relevant information into discharge assessment

Concerns raised1

Lack of a protocol for patients self-discharging from hospital without necessary medication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to provide cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Concerns raised1

Delays in dispatching discharge summaries

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised1

Failure to provide discharge summaries to GPs after emergency department attendance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

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

Actions described in response 1

Actions described in response 1

Actions described in response 1

Actions described in response 7

Actions described in response 3

Respondent positions 1

Actions described in response 7

Respondent positions 1