17 May 2017 Mr William Frederick Wilkes · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Delays in hospital discharge procedures View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr William Frederick Wilkes · 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
Mr William Frederick Wilkes was admitted to hospital after a fall at a residential home and remained in hospital after being assessed as ready for discharge. Delays in arranging suitable continuing healthcare placement, communication failures, and inconsistent provision of one-to-one enhanced care were identified; he suffered a further fall, fractured his hip, and died on 22 September 2016. The report raised concerns that discharge procedures were cumbersome and time-consuming and that local arrangements were needed to enable discharge within days rather than weeks.
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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 Delays in hospital discharge procedures
Wider context from the report “During the course of the inquest it became apparent that the protocol and procedure for discharge of someone from hospital was cumbersome and time-consuming . The result in this case was that, although the deceased was ready for discharge to a nursing home on the 19th July, he was not able to be transferred to a more appropriate care home prior to his death on 22nd September.
I also heard from the patient discharge lead from the hospital that the system was in urgent need of review .
Concerns
1. That a system needs to be put in place locally so that the procedures for effecting discharge can be implemented within days rather than weeks .
2. That a local protocol should be considered by both the Hospital Trust and the Clinical Commissioning Group for Milton Keynes.
” Source location Mr William Frederick Wilkes · Prevention of Future Deaths report
Open source report
20 Apr 2017 Charlotte Anne Agnew · Prevention of Future Deaths report City of London
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Concerns raised 1
Failure to put care plans in place before discharge View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Charlotte Anne Agnew · 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
Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.
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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 put care plans in place before discharge
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” Source location Charlotte Anne Agnew · Prevention of Future Deaths report
Open source report
Concerns raised 1
Delays in developing and implementing a safe discharge procedure View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Carol Ann Harvey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Carol Ann Harvey, aged seventy, was discharged from hospital with care planned at home, but no carers attended after a referral message was left without confirmation that it had been received. She was found the following morning drowsy, vomiting and having suffered significant blood loss, and died in hospital on 9 April 2016 following a paracetamol overdose and a pre-existing cardiac condition. The principal concerns were the lack of a procedure to confirm that referrals had been received and actioned, and delay in implementing a safe hospital discharge procedure.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in developing and implementing a safe discharge procedure
Wider context from the report “(b) The Action Plan which has been produced by the Health Board following an investigation into this death indicates that a Standard Operating Procedure for the safe discharge of patients from the Acute Hospital environment is being developed , however it was not possible to provide a completion and implementation date for this , notwithstanding that the death was eleven months ago. I am concerned that delays in undertaking work of this kind could place existing patients at risk .
” Source location Carol Ann Harvey · Prevention of Future Deaths report
Open source report
14 Feb 2017 Derek LEE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Incomplete mental-capacity documentation at discharge View source
This report raised 25 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Derek LEE · 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
Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.
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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 Incomplete mental-capacity documentation at discharge
Wider context from the report “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete .
” Source location Derek LEE · Prevention of Future Deaths report
Open source report
14 Feb 2017 Wendy Louise Telfer · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Delays in discharge caused by inadequate social and community care resources View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Devon Partnership NHS Trust NHS Devon Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Devon Partnership NHS Trust
Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
View source
Devon Partnership NHS Trust
Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
View source
Devon Partnership NHS Trust
Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
View source
Devon Partnership NHS Trust
Develop further alternatives to acute admission, including improved community support and additional step-down provision.
View source
NHS Devon Integrated Care Board
Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
View source
NHS Devon Integrated Care Board
Participate in workshops mapping current and future discharge and panel-approval processes.
View source
NHS Devon Integrated Care Board
Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
View source
NHS Devon Integrated Care Board
Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
View source
NHS Devon Integrated Care Board
Offer DPT additional management and consultative support from the urgent-care commissioning team.
View source
NHS Devon Integrated Care Board
Work with Devon County Council on care-home commissioning and market sufficiency for older people.
View source See 7 more actions
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AI-generated summary
Wendy Louise Telfer · 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
Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.
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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 Delays in discharge caused by inadequate social and community care resources
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients , and it is acknowledged that this is a wider issue of social and community care and resources . This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” Source location Wendy Louise Telfer · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop further alternatives to acute admission, including improved community support and additional step-down provision.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
Verbatim wording from the response “Monitoring of timely discharge performance data” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in workshops mapping current and future discharge and panel-approval processes.
Verbatim wording from the response “5. NEW Devon CCG, with Devon County Council representatives have participated in a series of workshops facilitated by DPT aimed at mapping current and future discharge and panel approval processes. NEW Devon CCG is awaiting the final report and recommendations for improvement in these processes from DPT;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
Verbatim wording from the response “6. NEW Devon CCG is already leading a process, working in partnership with Devon County Council to streamline current processes for the approval of joint funding of s117 aftercare and are working towards a simplified s117 aftercare funding agreement;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
Verbatim wording from the response “7. DPT have indicated a need for additional step down beds to be made available in the Exeter area and NEW Devon CCG is working with DPT to identify solutions for this need;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer DPT additional management and consultative support from the urgent-care commissioning team.
Verbatim wording from the response “8. NEW Devon CCG has offered DPT additional management and consultative support from its urgent care commissioning team who have had success in working with acute hospital providers to reduce delays in discharge;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Devon County Council on care-home commissioning and market sufficiency for older people.
Verbatim wording from the response “9. NEW Devon CCG is working closely with Devon County Council with regard to care home commissioning and market sufficiency for older people.” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Open published response
6 Feb 2017 Nuala Seddon · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to ensure clinical staff make discharge decisions View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Nuala Seddon · 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
Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.
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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 ensure clinical staff make discharge decisions
Wider context from the report “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation.
” Source location Nuala Seddon · Prevention of Future Deaths report
Open source report
25 Jan 2017 Mr Raymond Frank POLLARD · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2
Failure to medically review suitability for discharge View source Poorly informed discharge decision-making View source
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AI-generated summary
Mr Raymond Frank POLLARD · 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
Mr Raymond Frank Pollard was admitted to hospital with community-acquired pneumonia and respiratory and renal problems, including metabolic acidosis and high potassium levels. He was discharged to a rehabilitation nursing home without further arterial blood gas checks, a further doctor review, or reassessment before discharge, but became extremely unwell and required urgent hospital treatment. The principal concerns were that the discharge decision was poorly informed, that he was not reviewed for suitability for discharge, and that the failed discharge seriously compromised him.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to medically review suitability for discharge
Wider context from the report “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition.
(2) The patient was not seen again by a doctor or reviewed as to suitability for discharge .
(3) As a result the discharge failed and this failure seriously compromised Mr Pollard.
” Source location Mr Raymond Frank POLLARD · Prevention of Future Deaths report
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 Poorly informed discharge decision-making
Wider context from the report “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition .
(2) The patient was not seen again by a doctor or reviewed as to suitability for discharge.
(3) As a result the discharge failed and this failure seriously compromised Mr Pollard.
” Source location Mr Raymond Frank POLLARD · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the identified care concerns to identify required improvements and share learning with Respiratory Medicine staff.
Verbatim wording from the response “I am very sorry to read about the circumstances of Mr Pollard’s death and the concerns which you have highlighted. These issues have been reviewed by senior medical and nursing staff, including the Trust’s Head of Nursing, Discharge and Partnerships, to identify improvements required within the Directorate and to ensure that learning from this case is shared with staff in Respiratory Medicine.” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the discharge-related events through Directorate clinical governance meetings and staff training and awareness sessions.
Verbatim wording from the response “Events surrounding Mr Pollard’s discharge are being raised with nursing and medical staff through the Directorate clinical governance meetings and training/awareness sessions for staff which will continue this year, as a means of ensuring learning. These will focus on ensuring adherence to existing policies in respect of:” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatic medical review after discharge decisions is unnecessary because board rounds, nurse escalation and existing discharge policies provide sufficient safeguards.
Verbatim wording from the response “I do understand your concern about continuing medical review of complex patients following a decision that they are ready for discharge. The Trust is committed to ensuring that all available medical resources are used as effectively as possible; this includes prioritising those patients who will most benefit from direct medical input, rather than providing automatic medical review of all patients. The medical team does review the progress of all MRFD patients on the daily “board round” and will follow up any issues identified either as a result of that process, or arising from any request from clinical colleagues, including nurses. It is very important, therefore, that existing Trust policies are followed from the point when the patient’s discharge becomes nurse-led, in responding to changes in patients’ symptoms and appropriately requesting medical input.” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
Open published response
Concerns raised 1
Insufficient weekend hospital discharges contributing to bed blocking View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sarah Ann Tyler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Ann Tyler was admitted to the Emergency Department on 8 February 2015 following an overdose of co-codamol and, while awaiting admission, used ECG leads as a ligature, resulting in a hypoxic brain injury. The substantive concerns were delays in hospital admissions due to insufficient beds and more acute bed blocking at weekends because of reduced discharges.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient weekend hospital discharges contributing to bed blocking
Wider context from the report “1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions.
2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital .
” Source location Sarah Ann Tyler · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.
Verbatim wording from the response “Whilst the majority of patients are treated or admitted within the acceptable time, a significant minority took longer to be treated or admitted and a proportion of these will have waited significantly longer. The Health Board is required by Welsh Government to have a plan in place so that performance against the 4 hour target is improved, and that more patients are treated or admitted within 4 hours. The plan to achieve this improvement is set out in the Health Board’s plan for Unscheduled Care Plan, which is a chapter within the overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached in appendix 1. (The plan is a draft at this stage pending feedback on the draft from Welsh Government).” Source location 2017-0002-Response-by-University-Health-Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.
Verbatim wording from the response “Reducing Length of Stay
In addition to the work to reduce admissions, there is also a significant focus on reducing the time spent in hospital for patients that are admitted. Patients who experience a Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a support package to be provided in their own home. The Health Board carried out a detailed joint assessment of the issues that cause delay in December 2016 jointly with Local Authorities and the Independent Sector providers of care services (care home and home care). The plans to reduce DTOCs and length of stay are set out in the plan.” Source location 2017-0002-Response-by-University-Health-Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without wholesale changes to working practices, differences in hospital operations between Sundays and other days will continue.
Verbatim wording from the response “Bed availability at weekends
The Health Board does also ensure that doctors and discharge teams are available to support at weekends but, in the absence of a whole scale change in working practices, there will continue to be differences in the way that the hospital operates on a Sunday compared to other days in the week.” Source location 2017-0002-Response-by-University-Health-Board
Open published response
31 Oct 2016 James Francis Flynn · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3
Lack of detailed care plans for patient discharge View source Failure to inform immediate family of patient discharge View source Failure to ensure food or essential provisions are available after discharge for patients with diabetes View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
James Francis Flynn · 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
James Francis Flynn, who had chronic pancreatitis, was discharged home late on 8 December 2015 and was found unresponsive at home the following day; death was confirmed at 18:06. Concerns included discharge while he remained very unwell without a detailed care plan, with his immediate family unaware and no food or provisions available despite his type 2 diabetes, and that inadequate discharge planning and management could put patients’ lives at risk.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of detailed care plans for patient discharge
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place . His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” Source location James Francis Flynn · Prevention of Future Deaths report
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 inform immediate family of patient discharge
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” Source location James Francis Flynn · Prevention of Future Deaths report
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 ensure food or essential provisions are available after discharge for patients with diabetes
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic .
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” Source location James Francis Flynn · Prevention of Future Deaths report
Open source report
28 Oct 2016 Leslie Isaac LERNER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2
Failure to follow the hospital discharge protocol View source Failure to complete senior review before discharge View source
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Leslie Isaac LERNER · 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
Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow the hospital discharge protocol
Wider context from the report “14th May 2016
(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the day he was discharged without a Senior Review.
I was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised.
He was sent home with no analgesia. He should have been given analgesia. It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia.
The Hospital’s own Discharge Protocol was not followed , it should have been.
” Source location Leslie Isaac LERNER · Prevention of Future Deaths report
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 complete senior review before discharge
Wider context from the report “14th May 2016
(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the day he was discharged without a Senior Review .
I was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised.
He was sent home with no analgesia. He should have been given analgesia. It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia.
The Hospital’s own Discharge Protocol was not followed, it should have been.
” Source location Leslie Isaac LERNER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.