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.

17 May2017
Milton Keynes
Concerns raised1
1. Delays in hospital discharge procedures
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

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.

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 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
Page 2 · concerns
Open source report
20 Apr2017
City of London
Concerns raised1
1. Failure to put care plans in place before discharge
This report raised 7 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

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.

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 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
Page 3 · concerns
Open source report
10 Mar2017
North Wales (East and Central)
Concerns raised1
1. Delays in developing and implementing a safe discharge procedure
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.

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

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 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
Page 1 · concerns
Open source report
14 Feb2017
Brighton and Hove
Concerns raised1
1. Incomplete mental-capacity documentation at discharge
This report raised 25 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

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.

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
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
Page 2 · concerns
Open source report
14 Feb2017
Exeter and Greater Devon
Concerns raised1
1. Delays in discharge caused by inadequate social and community care resources
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 10
1. Action
  Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
  Stated by Devon Partnership NHS TrustStated completed
3. Action
  Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
  Stated by Devon Partnership NHS TrustStated completed
1. Action
  Develop further alternatives to acute admission, including improved community support and additional step-down provision.
  Stated by Devon Partnership NHS TrustStated in progress
2. Action
  Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
  Stated by NHS Devon Integrated Care BoardStated completed
3. Action
  Participate in workshops mapping current and future discharge and panel-approval processes.
  Stated by NHS Devon Integrated Care BoardStated completed
4. Action
  Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
  Stated by NHS Devon Integrated Care BoardStated in progress
5. Action
  Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
  Stated by NHS Devon Integrated Care BoardStated in progress
6. Action
  Offer DPT additional management and consultative support from the urgent-care commissioning team.
  Stated by NHS Devon Integrated Care BoardStated completed
7. Action
  Work with Devon County Council on care-home commissioning and market sufficiency for older people.
  Stated by NHS Devon Integrated Care BoardStated in progress
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.

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 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
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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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 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
Page 2 · response
Published 5 March 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 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
Page 1 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 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
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
Page 2 · response
Published 5 March 2017
Open published response
6 Feb2017
Inner North London
Concerns raised1
1. Failure to ensure clinical staff make discharge decisions
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.

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure 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
Page 2 · concerns
Open source report
25 Jan2017
Brighton and Hove
Concerns raised2
1. Failure to medically review suitability for discharge
2. Poorly informed discharge decision-making
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review the identified care concerns to identify required improvements and share learning with Respiratory Medicine staff.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Raise the discharge-related events through Directorate clinical governance meetings and staff training and awareness sessions.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Automatic medical review after discharge decisions is unnecessary because board rounds, nurse escalation and existing discharge policies provide sufficient safeguards.
  Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficient
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.

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 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
Page 3 · 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
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
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
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
Page 1 · response
Published 19 February 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
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
Page 2 · response
Published 19 February 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
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
Page 2 · response
Published 19 February 2017
Open published response
13 Jan2017
North Wales (East and Central)
Concerns raised1
1. Insufficient weekend hospital discharges contributing to bed blocking
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 2
1. Action
  Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.
  Stated by Betsi Cadwaladr University LHBStated planned
2. Action
  Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.
  Stated by Betsi Cadwaladr University LHBStated completed
Respondent positions 1
1. Position
  Without wholesale changes to working practices, differences in hospital operations between Sundays and other days will continue.
  Stated by Betsi Cadwaladr University LHBUnable to act
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.

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
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
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
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
Page 1 · response
Published 19 February 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
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
Page 2 · response
Published 19 February 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
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
Page 3 · response
Published 19 February 2017
Open published response
31 Oct2016
Milton Keynes
Concerns raised3
1. Lack of detailed care plans for patient discharge
2. Failure to inform immediate family of patient discharge
3. Failure to ensure food or essential provisions are available after discharge for patients with diabetes
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

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.

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 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
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to 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
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to 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
Page 1 · concerns
Open source report
28 Oct2016
Brighton and Hove
Concerns raised2
1. Failure to follow the hospital discharge protocol
2. Failure to complete senior review before discharge
This report raised 16 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

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.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to follow 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
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to 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
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in hospital discharge procedures

Concerns raised1

Failure to put care plans in place before discharge

Concerns raised1

Delays in developing and implementing a safe discharge procedure

Concerns raised1

Incomplete mental-capacity documentation at discharge

Concerns raised1

Delays in discharge caused by inadequate social and community care resources

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.10

Concerns raised1

Failure to ensure clinical staff make discharge decisions

Concerns raised2

Failure to medically review suitability for discharge

Poorly informed discharge decision-making

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Concerns raised1

Insufficient weekend hospital discharges contributing to bed blocking

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Actions described in response 10

Actions described in response 2

Respondent positions 1

Actions described in response 2

Respondent positions 1