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.

24 Oct2016
Leicester City and South Leicestershire
Concerns raised1
1. Failure to ensure accurate and complete discharge information is communicated to primary care teams
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Use a standardised discharge-letter template covering admission reasons and discharge diagnoses.
  Stated by University Hospitals of Leicester NHS TrustStated completed
2. Action
  Provide junior doctors with e-learning reinforcing accurate information in discharge letters to GPs.
  Stated by University Hospitals of Leicester NHS TrustStated completed
3. Action
  Request GP feedback and conduct regular audits of discharge-letter information quality.
  Stated by University Hospitals of Leicester NHS TrustStated completed
1. Action
  Increase the frequency of discharge-letter audits for each monthly QMG cycle.
  Stated by University Hospitals of Leicester NHS TrustStated planned
2. Action
  Extend GP feedback collection, review findings, discuss necessary actions, report to the Executive Quality Board, and repeat the audit at intervals.
  Stated by University Hospitals of Leicester NHS TrustStated planned
3. Action
  Discuss the case with the consultant involved to encourage reflective learning.
  Stated by University Hospitals of Leicester NHS TrustStated planned
4. Action
  Strengthen the Letters Policy to clarify discharge-letter procedures and senior medical oversight.
  Stated by University Hospitals of Leicester NHS TrustStated planned
5. Action
  Continue joint work through the LLR-wide discharge group to address IT barriers to electronic transfer of discharge letters to primary care.
  Stated by NHS Leicester City Clinical Commissioning GroupStated in progress
6. Action
  Report monthly discharge-letter audit results to the CCGs’ Contract team for formal oversight.
  Stated by NHS Leicester City Clinical Commissioning GroupStated planned
7. Action
  Develop a process for obtaining timely GP feedback on inaccurate discharge letters and supporting rapid correction and clinician learning.
  Stated by NHS Leicester City Clinical Commissioning GroupStated in progress
8. Action
  Include a discharge-letter quality indicator in the 2017–2018 UHL contract and formally monitor and report it, with corrective-action discussions if improvements are not sustained.
  Stated by NHS Leicester City Clinical Commissioning GroupStated planned
9. Action
  Include in the junior doctors’ induction programme an item emphasising accurate, timely information for primary care.
  Stated by NHS Leicester City Clinical Commissioning GroupStated planned
Respondent positions 1
1. Position
  Responsibility for commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Margaret Mary Dempsie · 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

Margaret Mary Dempsie, who had advanced dementia and frailty, was admitted to hospital for treatment of infected leg ulcers, later deteriorated with sepsis, and died two days after discharge for end-of-life care. The discharge letter contained inaccurate and incomplete clinical information, including an incorrect reference to aspiration pneumonia and omission of pyelonephritis, raising concerns that vulnerable patients could receive inappropriate care based on incorrect discharge information.

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 accurate and complete discharge information is communicated to primary care teams
Wider context from the report
“The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dempsie was not surprised and admitted in the inquest that the Discharge Letters for patients were being completed with mistakes by the Junior Doctors, that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts. He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes being made in the care of vulnerable patients newly discharged from hospital. ”
Source location
Margaret Mary Dempsie · 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
Use a standardised discharge-letter template covering admission reasons and discharge diagnoses.

Verbatim wording from the response
“Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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 junior doctors with e-learning reinforcing accurate information in discharge letters to GPs.

Verbatim wording from the response
“Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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
Request GP feedback and conduct regular audits of discharge-letter information quality.

Verbatim wording from the response
“In addition, the Trust has for some time requested individualised feedback from GP’s regarding any poor or inaccurate information received from the Trust and undertakes regular audits to provide assurance on the quality of the information provided in Discharge Letters. These audits show an improvement in the quality of the information that we provide to GP’s.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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
Increase the frequency of discharge-letter audits for each monthly QMG cycle.

Verbatim wording from the response
“1. The frequency of internal audits for discharge letters will be increased for each QMG every month with immediate effect and our Head of Outcomes and Effectiveness will lead on this.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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
Extend GP feedback collection, review findings, discuss necessary actions, report to the Executive Quality Board, and repeat the audit at intervals.

Verbatim wording from the response
“2. Our Chief Medical Information Officer and Head of Services for GP’s will encourage GP’s to provide individualised and patient specific feedback concerning poor discharge letters throughout December 2016 to assess the level of inaccuracies and perception of poor Discharge letters. Our Chief Medical Information Officer will then review any feedback and discuss necessary actions with the doctors involved and the GP dependant upon the findings. He will report on this matter to the Executive Quality Board in March 2017. Our Head of Services for GP’s will promote the opportunities to feedback errors on discharge letters directly to her in the December GP Newsletter. This extended audit will then be repeated at regular intervals, depending on the findings.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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 the case with the consultant involved to encourage reflective learning.

Verbatim wording from the response
“4. Our Medical Director will ensure that this case is discussed with the Consultant involved before the end of December 2016 to encourage reflective learning. ████████ has met with the junior doctor who wrote the discharge”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 2016
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 the Letters Policy to clarify discharge-letter procedures and senior medical oversight.

Verbatim wording from the response
“5. Our Head of Outcomes and Effectiveness will strengthen our “Letters Policy” to ensure that there is clarity concerning the process for discharge letters and the importance of senior medical oversight. This should go to the Policy and Guideline Committee Meeting in January 2017.”

Source location
2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 3 · response
Published 24 October 2016
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
Continue joint work through the LLR-wide discharge group to address IT barriers to electronic transfer of discharge letters to primary care.

Verbatim wording from the response
“This CCG and our two commissioning partners in Leicestershire and Rutland recognise that the provision of accurate and timely discharge information is a prerequisite for safe and high quality patient care. We have been working together with University Hospitals of Leicester (UHL) to address this and have taken a number of concrete actions:-”

Source location
2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 1 · response
Published 24 October 2016
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
Report monthly discharge-letter audit results to the CCGs’ Contract team for formal oversight.

Verbatim wording from the response
“• UHL undertakes an audit of a sample of discharge letters on a monthly basis, assessing their content and timeliness, with feedback directly to the clinician concerned. The trust reports that they have seen an improvement in both the quality and the accuracy of letters since this started. This monthly audit will continue, and the results will now be reported into the CCGs Contract team for formal overview.”

Source location
2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 1 · response
Published 24 October 2016
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 a process for obtaining timely GP feedback on inaccurate discharge letters and supporting rapid correction and clinician learning.

Verbatim wording from the response
“• Getting accurate feedback from GPs whenever there is a problem with Discharge letters is a key part of improving performance. We are currently in discussion with UHL and our GP Colleagues about how this can best be done, probably through a dedicated email contact point. The intention is to get feedback within 24 to 36 hours of receipt of the letter, with rapid contact with the relevant junior doctor both to increase their learning but also to ensure the provision of a corrected an accurate discharge letter where necessary. We are exploring the feasibility of this over the coming weeks.”

Source location
2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 2016
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
Include a discharge-letter quality indicator in the 2017–2018 UHL contract and formally monitor and report it, with corrective-action discussions if improvements are not sustained.

Verbatim wording from the response
“• To ensure there is an ongoing focus on the quality of Discharge letters, the 2017 / 2018 contract with UHL will include a quality indicator within the contract which will be formally monitored and reported to the contract team. This will include discussions around corrective action should the necessary improvements not be sustained. The contracts are due to be agreed by the 23rd of December 2016.”

Source location
2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 2016
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
Include in the junior doctors’ induction programme an item emphasising accurate, timely information for primary care.

Verbatim wording from the response
“• The CCGs are currently in discussion with UHL about the content of their junior doctors Induction programme. We will ensure that an item is included within this programme which highlights the importance of getting accurate information out to primary care colleagues as soon as possible to ensure the appropriate delivery of care to patients.”

Source location
2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 2016
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 commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.

Verbatim wording from the response
“I have reviewed your report in detail and I have identified that the Leicester City Clinical Commissioning Group (“CCG”) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. I have therefore asked the CCG to respond and provide assurance regarding actions they have taken in order to mitigate the risk identified within your report. A copy of their response is enclosed with this letter.”

Source location
2016-0374-Response-by-NHS-England
Page 1 · response
Published 24 October 2016
Open published response
18 Oct2016
Manchester (City)
Concerns raised1
1. Inadequate pre-discharge risk assessment
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

John Graham SMITH · Prevention of Future Deaths report

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

Report summary

Mr Smith was discharged home after admission following a fall, despite concerns about his dementia, incontinence, mobility, difficult stairs and ability to care for himself and his wife. He was readmitted after another fall at home, underwent surgery for a fractured neck of femur, developed aspiration pneumonia and died. The principal concerns were inadequate risk assessment and questioning before discharge, including insufficient consideration of his toileting needs and the difficult staircase.

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
Inadequate pre-discharge risk assessment
Wider context from the report
“1. Inadequate risk assessment prior to discharge – evidence heard in court confirmed that the assessment was done using 3 standard steps/stairs. There was no consideration of toilet needs requiring urgent toileting and Mr Smith having to climb a difficult staircase in a hurry. Further, there were professional and family concerns raised regarding discharge. ”
Source location
John Graham SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Aug2016
Rutland and North Leicestershire
Concerns raised3
1. Lack of support for high-risk patients and their main carers after discharge
2. Failure to maintain documentary proof of discharge notification calls
3. Failure to provide immediate written discharge and high-risk notification to the crisis team
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

Anthony John Preston · 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

Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

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 support for high-risk patients and their main carers after discharge
Wider context from the report
“(4) As a result, Mr Preston and his main carer ████████ were left without support at a time when he was at high risk. ”
Source location
Anthony John Preston · 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 maintain documentary proof of discharge notification calls
Wider context from the report
“(2) The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust. There was no documentary proof of the telephone call. ”
Source location
Anthony John Preston · 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 provide immediate written discharge and high-risk notification to the crisis team
Wider context from the report
“(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home. ”
Source location
Anthony John Preston · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Aug2016
West Yorkshire Eastern
Concerns raised1
1. Breakdown in hospital-to-prison discharge communication
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

Thomas George Jordan · 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

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

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
Breakdown in hospital-to-prison discharge communication
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Source location
Thomas George Jordan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jun2016
Birmingham and Solihull
Concerns raised2
1. Failure to ensure completion of outstanding tests before discharge
2. Failure to document outstanding test results and required follow-up in discharge records
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

Terence Henry Stilges · 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 Henry Stilges was admitted to hospital after collapsing, was discharged before an outstanding troponin result was available, and was readmitted with severe shortness of breath and chest pain. He was diagnosed with an acute myocardial infarction and died following a cardiac arrest; the principal concern was that advance preparation of discharge summaries and incorrect discharge instructions could lead to patients being discharged before tests were complete.

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 completion of outstanding tests before discharge
Wider context from the report
“(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete. ”
Source location
Terence Henry Stilges · 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 document outstanding test results and required follow-up in discharge records
Wider context from the report
“(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete. ”
Source location
Terence Henry Stilges · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Jun2016
West Sussex
Concerns raised1
1. Lack of a policy for discharge counselling and warning cards for Apixaban
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.
Actions described in response 7
1. Action
  Launch and maintain a NOAC alert card for patients prescribed apixaban and other new oral anticoagulants.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Introduce a pharmacy standard operating procedure supporting NOAC alert-card distribution.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Adopt the Patient First methodology to review the entire NOAC care process.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
1. Action
  Revise the anticoagulant prescribing and administration policy to capture NOAC counselling, consent and written-information standards.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
2. Action
  Establish a multidisciplinary group to design and introduce mechanisms embedding the revised NOAC policy in practice.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
3. Action
  Formalize electronic recording of NOAC counselling discussions.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
4. Action
  Introduce patient leaflets supporting the NOAC alert card.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
AI-generated summary

Valerie Margaret Ellis · 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

Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.

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 policy for discharge counselling and warning cards for Apixaban
Wider context from the report
“1) On discharge from the hospital the use of Apixaban in an elderly confused patient being cared for by a carer with hearing loss should have merited careful counselling by the clinicians and the use of a warning card. Whilst the hospital is taking steps to assess this area, my understanding is that no policy has been adopted and I feel it should be made a matter of urgency. ”
Source location
Valerie Margaret Ellis · 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
Launch and maintain a NOAC alert card for patients prescribed apixaban and other new oral anticoagulants.

Verbatim wording from the response
“The Trust has welcomed the opportunity to build upon the work already in place to ensure that patients prescribed Apixaban receive the very best information about the potential side-effects. Despite the absence of national guidance, the Trust has continued to strive to develop a system to ensure that both counselling and a warning card provide patients and their carers with a firm understanding of the risks, as well as the benefits, of this and other new oral anticoagulants (NOAC).”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 1 · response
Published 16 June 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce a pharmacy standard operating procedure supporting NOAC alert-card distribution.

Verbatim wording from the response
“As you will be aware, the Trust launched the NOAC alert card in October 2015 and introduced a Standard Operating Procedure to enable pharmacy staff to be fully appraised of the new system and to support the distribution of the warning card. In addition, daily reminders generated by the electronic prescribing software ensure that new patients are identified. It is hoped to strengthen the system still further by placing a further NOAC card in the medication bag given to patients on discharge and to ensure that all discussions with relatives and carers regarding the new drug are documented.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 1 · response
Published 16 June 2016
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
Adopt the Patient First methodology to review the entire NOAC care process.

Verbatim wording from the response
“The Patient First initiative sits at the very heart of the Western Sussex NHS Foundation Trust’s vision of continuous improvement and provides a framework for reviewing each stage of a patient care process. While the above actions seek to address the former inadequacies of the counselling process, it is intended to adopt this methodology to review the entire NOAC process. The standards are being captured in the revised policy for prescribing and administration of anti-coagulants. The policy includes that newly initiated patients are consented by the medical staff as treatment is initiated and receive written information and counselling during the stay and at discharge from nursing and pharmacy staff.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2016
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
Revise the anticoagulant prescribing and administration policy to capture NOAC counselling, consent and written-information standards.

Verbatim wording from the response
“The Patient First initiative sits at the very heart of the Western Sussex NHS Foundation Trust’s vision of continuous improvement and provides a framework for reviewing each stage of a patient care process. While the above actions seek to address the former inadequacies of the counselling process, it is intended to adopt this methodology to review the entire NOAC process. The standards are being captured in the revised policy for prescribing and administration of anti-coagulants. The policy includes that newly initiated patients are consented by the medical staff as treatment is initiated and receive written information and counselling during the stay and at discharge from nursing and pharmacy staff.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a multidisciplinary group to design and introduce mechanisms embedding the revised NOAC policy in practice.

Verbatim wording from the response
“Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2016
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
Formalize electronic recording of NOAC counselling discussions.

Verbatim wording from the response
“Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2016
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 patient leaflets supporting the NOAC alert card.

Verbatim wording from the response
“Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.”

Source location
2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Page 2 · response
Published 16 June 2016
Open published response
13 Jun2016
London (East)
Concerns raised1
1. Inadequate safety planning on discharge
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.

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

Laura McRory · 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

Laura McRory, who had a history of anxiety, depression and alcohol misuse, was assessed at hospital on 20 June 2015 after deterioration in her mental state and increased alcohol consumption. She was discharged without immediate follow-up or continued observation and was found unresponsive the following day; she died from alcohol and mixed drug consumption. The principal concerns were the adequacy of the discharge safety plan and the lack of a clear process for referring NELFT staff seeking mental healthcare to another Trust when they were unwilling to share information with colleagues.

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
Inadequate safety planning on discharge
Wider context from the report
“• The Trust’s investigation report found that there were no care or service delivery problems. The report however did not analyse to any degree the issues relating to the complexities surrounding NELFT employees seeking help for mental health conditions. The report also did not to any extent consider whether there was an adequate safety plan in place on discharge. ”
Source location
Laura McRory · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Jun2016
Blackburn, Hyndburn and Ribble Valley
Concerns raised3
1. Failure to hold a final discharge meeting for discharge to a rehabilitation unit
2. Failure to arrange familiarisation visits before discharge to a rehabilitation unit
3. Failure to assess current presentation and circumstances before rescinding detention and arranging discharge
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.

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

Tracey Lynch · 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

Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.

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 hold a final discharge meeting for discharge to a rehabilitation unit
Wider context from the report
“1. Despite the fact that there had been a clear change in the presentation of Tracey Lynch following the CPA Meeting on the 22nd June and despite the fact that arrangements for discharge were not in place until the 28th September 2015 no final discharge meeting was held, that is despite the fact that the responsible clinician, ████████ the care co-ordinator ████████ and the deputy manager from Oswald House ████████ had all indicated that they wished there to be a final discharge meeting. There seemed to be no system in place to ensure that such a meeting would take place and in order to ensure that appropriate management would take place of the discharge to a rehabilitation unit. ”
Source location
Tracey Lynch · 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 arrange familiarisation visits before discharge to a rehabilitation unit
Wider context from the report
“2. The evidence was that familiarisation visits would have been of considerable assistance to Miss Lynch in the lead up to her discharge to Oswald House. Despite that being accepted there appeared to be no system in place to ensure that such familiarisation visits would take place. ”
Source location
Tracey Lynch · 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 assess current presentation and circumstances before rescinding detention and arranging discharge
Wider context from the report
“4. Having been detained by the Police and having then been assessed by Mental Health Practitioners Tracey Lynch was then detained under Section 3 of the Mental Health Act 1983. She was taken from Preston Police Station to The Harbour at Blackpool. She was placed on a different ward and with a different responsible clinician, ████████ Without carrying out any form of assessment whatsoever and with only a cursory glance at previous records ████████ immediately rescinded the Section 3 and without any consideration of the change in circumstance and presentation of Miss Lynch arranged for her immediate discharge to Oswald House. The evidence was that the Consultant Psychologist ████████ who had previously been dealing with Miss Lynch attempted to contact ████████ but her offer of assistance was refused. Having been detained for a second time there was no assessment and no care programme approach meeting arranged. That appeared to be a serious systems failure. ”
Source location
Tracey Lynch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 May2016
Inner North London
Concerns raised1
1. Failure to communicate clinical expectations to patients and families before discharge
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.

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

Komang Jack SUSIANTA · 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

Jack was a 17-year-old boy who developed a drug-related psychotic episode after taking cannabis and ecstasy, was detained by police and taken to hospital, and was discharged after assessment. His condition deteriorated after discharge; he later entered a river while being pursued by police and drowned. The principal concern was that the hospital did not communicate to his family the expected recovery, warning signs of recurrence, or when and how to seek urgent professional help.

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 communicate clinical expectations to patients and families before discharge
Wider context from the report
“The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”
Source location
Komang Jack SUSIANTA · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Apr2016
Manchester South
Concerns raised2
1. Failure to ensure prescribed antibiotics are supplied to patients on discharge
2. Failure to provide discharge information to the GP
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 3
1. Action
  Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.
  Stated by Manchester University NHS Foundation TrustStated completed
2. Action
  Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.
  Stated by Manchester University NHS Foundation TrustStated completed
3. Action
  Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.
  Stated by Manchester University NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Emergency Department attendance notifications are not sent because local GPs agreed they were unnecessary; formal discharge letters follow inpatient stays only.
  Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Patrick McGagh · 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

Patrick McGagh died at his care home from natural causes; the medical cause of death was recorded as pneumonia, coronary artery atheroma and hypertensive heart disease. After discharge from hospital, no discharge information or prescribed antibiotics were provided to his GP or care staff, who were therefore unaware that he should have been taking 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 ensure prescribed antibiotics are supplied to patients on discharge
Wider context from the report
“On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics. ”
Source location
Patrick McGagh · 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 provide discharge information to the GP
Wider context from the report
“On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics. ”
Source location
Patrick McGagh · 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
Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.

Verbatim wording from the response
“Actions taken:”

Source location
2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016
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
Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.

Verbatim wording from the response
“It is documented within the clinical records that Mr McGagh’s carer was advised regarding using a scrotal support and also to monitor for any skin changes and for Mr McGagh to return to hospital urgently if any concerns or his symptoms deteriorate. It is not explicit within the records if the carer in attendance was advised regarding the antibiotics. We agree apologise for this omission, all clinical ED staff have been reminded of the importance of supplying verbal and written instruction as required and this interaction must then be documented in the clinical health records.”

Source location
2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016
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
Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.

Verbatim wording from the response
“To support ongoing improvements a regular audit program within the ED to monitor compliance with the policy and documentation has been commenced. Any individual staff identified that are not adhering to the required processes will be managed accordingly.”

Source location
2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 3 · response
Published 28 April 2016
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
Emergency Department attendance notifications are not sent because local GPs agreed they were unnecessary; formal discharge letters follow inpatient stays only.

Verbatim wording from the response
“The Trust does not send notification of attendance to the Emergency Department. This decision was made following consultation with local GP’s, where it was agreed that the ED would no longer issue a notification of attendance on discharge from the ED. Formal discharge letters are produced only following an in-patient stay.”

Source location
2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure accurate and complete discharge information is communicated to primary care teams

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.12

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

Concerns raised1

Inadequate pre-discharge risk assessment

Concerns raised3

Lack of support for high-risk patients and their main carers after discharge

Failure to maintain documentary proof of discharge notification calls

Failure to provide immediate written discharge and high-risk notification to the crisis team

Concerns raised1

Breakdown in hospital-to-prison discharge communication

Concerns raised2

Failure to ensure completion of outstanding tests before discharge

Failure to document outstanding test results and required follow-up in discharge records

Concerns raised1

Lack of a policy for discharge counselling and warning cards for Apixaban

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

Actions described in response 12

Respondent positions 1

Actions described in response 7