Recurring concern

Unreliable hospital discharge processes

First to latest report 30 Jan 2013 — 10 Jun 2026

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

What this concern includes

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

What is not included

Inter-hospital patient transfer where no discharge from hospital care occurs
Failures in treatment after a safe and complete discharge
Generic care coordination unrelated to a hospital discharge process
Delays in admission or movement within hospital before discharge is being planned

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 273 reports

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

16 Mar2016
Manchester West
Concerns raised1
1. Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm
Linked response

North West Boroughs Healthcare NHS Foundation Trust
Stated actions 2
1. North West Boroughs Healthcare NHS Foundation Trust
  Amend the Community Treatment Order Procedure to address the identified concerns.
2. North West Boroughs Healthcare NHS Foundation Trust
  Communicate the amended Community Treatment Order Procedure to staff.
AI-generated summary

Helen England · 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

Helen England, who had bipolar affective disorder and was subject to a Community Treatment Order, was found hanging in her home on 26 December 2013 after recent self-harm, hospital discharge and concerns about her safety. The principal concern was that there was no protocol or guidance for mental health nurses on whether to refer discharge decisions to a doctor, particularly when a patient subject to a Community Treatment Order had attended or been admitted to hospital following self-harm.

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 protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm
Wider context from the report
“There was no protocol nor any guidance in place for Mental Health Nurses at the 5 Boroughs NHS Partnership Foundation Trust to follow when considering whether or not to refer to a Doctor a decision to discharge a patient, following an attendance at, or admission to, an acute Hospital consequent upon an episode of self-harm, particularly when the patient is subject to a Community Treatment Order imposed under the terms of the Mental Health Act. ”
Source location
Helen England · 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
Amend the Community Treatment Order Procedure to address the identified concerns.

Verbatim wording from the response
“I am writing to inform you that although the Regulation 28 was not aimed specifically at the Trust I would like to confirm that our Community Treatment Order Procedure has been amended in light of your concerns and the processes for communicating this to our staff is underway.”

Source location
Helen-England-Response
Page 2 · response
Published 16 March 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
Communicate the amended Community Treatment Order Procedure to staff.

Verbatim wording from the response
“I am writing to inform you that although the Regulation 28 was not aimed specifically at the Trust I would like to confirm that our Community Treatment Order Procedure has been amended in light of your concerns and the processes for communicating this to our staff is underway.”

Source location
Helen-England-Response
Page 2 · response
Published 16 March 2016
Open published response
29 Feb2016
Manchester (North)
Concerns raised3
1. Failure to involve the patient’s Primary/Associate Nurse in discharge
2. Failure to review discharge decisions after material changes in patient presentation
3. Disjointed and uncoordinated discharge processes
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Pennine Care NHS Foundation Trust
Stated actions 2
1. Pennine Care NHS Foundation Trust
  Implement a robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.
2. Pennine Care NHS Foundation Trust
  Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.
AI-generated summary

Susan Beverley George · 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

Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

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 involve the patient’s Primary/Associate Nurse in discharge
Wider context from the report
“2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse. ”
Source location
Susan Beverley George · 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
Failure to review discharge decisions after material changes in patient presentation
Wider context from the report
“1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled. ”
Source location
Susan Beverley George · 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
Disjointed and uncoordinated discharge processes
Wider context from the report
“2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse. ”
Source location
Susan Beverley George · 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
Implement a robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.

Verbatim wording from the response
“The ward has appointed a substantive Ward Manager since this case and the development of a more robust discharge process has now been implemented.”

Source location
Susan-George-Response
Page 3 · response
Published 29 February 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
Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.

Verbatim wording from the response
“The current discharge protocol will be reviewed to ensure it is still reflective of all required processes and add a note of guidance to staff should they be faced with a similar situation.”

Source location
Susan-George-Response
Page 4 · response
Published 29 February 2016
Open published response
23 Feb2016
Manchester South
Concerns raised1
1. Failure to allow sufficient time to assess tolerance of a newly started drug before discharge
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Stockport NHS Foundation Trust
Respondent positions 1
1. Stockport NHS Foundation Trust
  The Trust considers post-initiation hospital observation unnecessary because serious Septrin adverse events are more likely after prolonged treatment.
  No action considered necessary
AI-generated summary

Freda Weston · 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

Freda Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.

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 allow sufficient time to assess tolerance of a newly started drug before discharge
Wider context from the report
“1. She was discharged from hospital after being started on the Septrin without allowing sufficient time to ensure that the new drug “suited” her. ”
Source location
Freda Weston · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
The Trust considers post-initiation hospital observation unnecessary because serious Septrin adverse events are more likely after prolonged treatment.

Verbatim wording from the response
“The Surgical and Critical Care Team do not feel that a period of observation in hospital after starting Septrin would be beneficial, as the most serious adverse events that can occur while taking Septrin are more likely to occur after being on Septrin for a more prolonged period. The advice recommended by the various manufacturers of Septrin is to monitor the patient’s blood results monthly, therefore the Trust will continue to abide by this recommendation. Notwithstanding this, Mrs Weston remained on the ward for a further week, prior to her discharge on 22 April 2015 and was well at the time of discharge.”

Source location
Weston-Response
Page 1 · response
Published 23 February 2016
Open published response
11 Feb2016
Brighton and Hove
Concerns raised4
1. Failure to provide patients with discharge-summary copies and an understanding of their significance
2. Failure to send hospital discharge summaries electronically to GPs on the day of discharge
3. Failure to identify recent failed discharges during discharge planning
1. Failure to apply discharge policy and begin discharge documentation at the start of the care journey
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marion Rose HOWES · 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

Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable 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
Failure to provide patients with discharge-summary copies and an understanding of their significance
Wider context from the report
“(1) Discharge summaries from the hospital These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital. In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge. ”
Source location
Marion Rose HOWES · 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 send hospital discharge summaries electronically to GPs on the day of discharge
Wider context from the report
“(1) Discharge summaries from the hospital These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital. In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge. ”
Source location
Marion Rose HOWES · 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 identify recent failed discharges during discharge planning
Wider context from the report
“(4) In Mrs. Howes’ case there were two failed discharges. The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced, or wasn't in Mrs. Howes case. I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies. It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't. It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance. I understand that that is not available at weekends, and so presumably complex patients should not be discharged at weekends or bank holidays. ”
Source location
Marion Rose HOWES · 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 apply discharge policy and begin discharge documentation at the start of the care journey
Wider context from the report
“(4) In Mrs. Howes’ case there were two failed discharges. The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced, or wasn't in Mrs. Howes case. I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies. It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't. It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance. I understand that that is not available at weekends, and so presumably complex patients should not be discharged at weekends or bank holidays. ”
Source location
Marion Rose HOWES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jan2016
Manchester South
Concerns raised1
1. Failure to assess patients and ensure medical and social factors are in place before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Stockport NHS Foundation Trust
Respondent positions 1
1. Stockport NHS Foundation Trust
  The consultant-led written discharge plan was followed, providing sufficient arrangements for discharge despite the discharging doctor not personally seeing the patient.
  Existing arrangements considered sufficient
AI-generated summary

Steven Leslie Rogers · 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

Steven Leslie Rogers was admitted to Stepping Hill Hospital on 20 August 2015 with reduced consciousness and confusion and a history of unstable type 1 diabetes. His long-acting Levemir insulin was accidentally omitted during his admission, and he was discharged by a consultant who had not seen him; he was found dead at home two days later, having died from diabetic keto-acidosis. The substantive concerns were the discharge process and the omission and subsequent alteration of his insulin regimen.

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 assess patients and ensure medical and social factors are in place before discharge
Wider context from the report
“1. The doctor who discharged the patient from the hospital as being “medically fit for discharge” did so without ever seeing the patient. In his statement to the inquest he says “I am afraid I have never seen Mr Rogers.......... he was seen by two consultant colleagues........... I was asked if he could go home by one of the nurses.....was shown the notes ..... asked the nurse to follow the team’s pre-arranged plan i.e. to discharge the patient. It is noted that Mr Rogers went home by bus”. The fact that a doctor not only discharges a patient in this way but also has no compunction in saying that he has done so in a statement to a Coroner, suggests a fundamental lack of understanding as to the importance of ensuring that all factors are in place for discharge, including medical and social issues. ”
Source location
Steven Leslie Rogers · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
The consultant-led written discharge plan was followed, providing sufficient arrangements for discharge despite the discharging doctor not personally seeing the patient.

Verbatim wording from the response
“It is normal practice for all patients to have a written plan by a consultant in relation to their discharge.”

Source location
Steven-Rogers-Response
Page 1 · response
Published 20 January 2016
Open published response
7 Jan2016
West Sussex
Concerns raised3
1. Failure to communicate required discharge-assessment factors to the assessor
2. Failure of assessment notes to clearly and accurately record information for the discharge decision-maker
3. Lack of clarity about required coverage in discharge assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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

Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early discharge.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate required discharge-assessment factors to the assessor
Wider context from the report
“(2) Factors that the person making the decision for early discharge required to be covered in the assessment process were not brought to the attention of the person who was to carry out that assessment. ”
Source location
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
Page 4 · 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 of assessment notes to clearly and accurately record information for the discharge decision-maker
Wider context from the report
“(3) The assessment notes were not completely clear and accurate in recording the information to be provided to the person making the decision to discharge. ”
Source location
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity about required coverage in discharge assessments
Wider context from the report
“(1) When taking what was described as an ‘exceptional course’ in deciding to discharge the patient at an early stage, there was lack of clarity and understanding as to what the person making the decision to discharge required to be covered in the discharge assessment process. ”
Source location
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
Page 4 · concerns
Open source report
15 Sep2015
Surrey
Concerns raised1
1. Lack of discharge follow-up mechanisms for patients transferring to a different area
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Surrey and Borders Partnership NHS Foundation Trust
Stated actions 3
1. Surrey and Borders Partnership NHS Foundation Trust
  Review Home Treatment Team processes for sharing information with new providers after service users relocate.
2. Surrey and Borders Partnership NHS Foundation Trust
  Remind Home Treatment Team staff of local discharge and follow-up procedures for relocated service users.
3. Surrey and Borders Partnership NHS Foundation Trust
  Obtain relocated service users’ residence and GP details, refer them to local mental health services, and notify the original GP where required.
Respondent positions 1
1. Surrey and Borders Partnership NHS Foundation Trust
  Ensuring relocated patients receive appropriate mental health support is challenging when they have not registered with a GP because services are mainly GP-aligned.
  Unable to act
AI-generated summary

George Nigel Palmer · 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

George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be made.

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 discharge follow-up mechanisms for patients transferring to a different area
Wider context from the report
“During the inquest ████████ Registered Mental Health Nurse, provided helpful evidence and the following concerns were highlighted: - • Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. • Appropriateness of follow up letters to the patient in the event of non-contact. I would ask that you consider giving further consideration to the above to ensure that there is no further repetition. ”
Source location
George Nigel Palmer · 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
Review Home Treatment Team processes for sharing information with new providers after service users relocate.

Verbatim wording from the response
“Further to the Inquest, we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged from our services due to their relocation to other parts of the country. Staff in the Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team.”

Source location
2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 1 · response
Published 15 September 2014
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 Home Treatment Team staff of local discharge and follow-up procedures for relocated service users.

Verbatim wording from the response
“Further to the Inquest, we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged from our services due to their relocation to other parts of the country. Staff in the Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team.”

Source location
2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 1 · response
Published 15 September 2014
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
Obtain relocated service users’ residence and GP details, refer them to local mental health services, and notify the original GP where required.

Verbatim wording from the response
“As per our local protocol, our staff will ensure that when they are made aware of the eminent relocation of a person who still requires use of mental health services, they will request from the person, information relating to their new location of residence including GP details. This is to enable us to refer to another provider of Mental Health Services local to them. If the person is yet to be registered with a new GP, we will refer to local services in that new location and also inform their original GP of the discharge and any further referrals for completeness. If a person is temporarily registered with a GP in this area, then their original GP is also notified.”

Source location
2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 1 · response
Published 15 September 2014
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
Ensuring relocated patients receive appropriate mental health support is challenging when they have not registered with a GP because services are mainly GP-aligned.

Verbatim wording from the response
“We accept that follow-up letters alone are not sufficient as a means of contact or a way to ensure that people are receiving mental health support in new areas of residence. It is at times quite challenging for us to ensure that a person who has relocated to a new area is receiving the right level of Mental Health support if they have not registered with a GP as the majority of teams are GP aligned. We however work to ensure that people are well supported; for example if a patient using our service chooses to visit family/friends in another area for a period of time, then we proactively ask if they would like mental health input whilst visiting another and a referral is made, supplying information such as current medication prescribed, risk assessment and Care plans.”

Source location
2015-0407-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Page 2 · response
Published 15 September 2014
Open published response
12 Aug2015
Brighton and Hove
Concerns raised1
1. Lack of joined-up care and discharge planning in the Acute Medical Unit
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals Sussex NHS Foundation Trust
Respondent positions 1
1. University Hospitals Sussex NHS Foundation Trust
  The records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.
  Disputes the concern
AI-generated summary

Thelma Patricia JONES · 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

Thelma Patricia JONES was admitted to the Acute Medical Unit from 16 to 23 February 2015, became acutely unwell, and was moved to intensive therapy after being intubated on the unit. The concerns were limited evidence of coordinated care planning and incomplete National Early Warning System scoring after her acute deterioration and a medical emergency team call on 23 February 2015.

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 joined-up care and discharge planning in the Acute Medical Unit
Wider context from the report
“This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU. • firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that. • The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed. This is extremely poor; it is a matter that I have raised before and it must, please, be addressed. ”
Source location
Thelma Patricia JONES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
The records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.

Verbatim wording from the response
“Having reviewed the medical records we consider that there is evidence that suitable care and treatment were provided and that discharge arrangements were planned and coordinated.”

Source location
2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 12 August 2015
Open published response
11 Aug2015
Surrey
Concerns raised1
1. Failure to document care plans for family members undertaking care obligations
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Julia Ann Clarke Hayward · 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

Julia Ann Clarke Hayward died on 23 May 2014 after intentionally placing herself in the path of an oncoming train while suffering from mental illness. The inquest identified concern that care plans agreed when discharging mental health patients into the care of family members were not documented or provided to those family members, leading to uncertainty about their obligations.

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 document care plans for family members undertaking care obligations
Wider context from the report
“During the course of the inquest the evidence revealed that when a decision was made to discharge a patient home and into the care of a family member, following a mental health assessment. The Care Plan was agreed orally and not documented for the family member. Consequently, issues arose as to what was expected/anticipated of the family member under the Care Plan and what was understood by that family member as being their obligations. ”
Source location
Julia Ann Clarke Hayward · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Jul2015
Manchester North
Concerns raised1
1. Failure to document discharge risk-factor assessments in clinical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Toni Piel · 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

Toni Piel suffered a head injury in a fall at home on 10 December 2014 and was treated at hospital before being discharged. He was found dead at home on 23 December 2014, with the inquest concluding that he died from a head injury caused by a fall, although it was not established whether this was linked to the earlier injury. Concerns included that his home circumstances and the absence of anyone able to observe him were apparently not considered at discharge, and that risk factors were not documented.

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 document discharge risk-factor assessments in clinical records
Wider context from the report
“i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account. ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records. ”
Source location
Toni Piel · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm

Linked response

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

Concerns raised3

Failure to involve the patient’s Primary/Associate Nurse in discharge

Failure to review discharge decisions after material changes in patient presentation

Disjointed and uncoordinated discharge processes

Linked response

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

Concerns raised1

Failure to allow sufficient time to assess tolerance of a newly started drug before discharge

Linked response

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

Concerns raised4

Failure to provide patients with discharge-summary copies and an understanding of their significance

Failure to send hospital discharge summaries electronically to GPs on the day of discharge

Failure to identify recent failed discharges during discharge planning

Failure to apply discharge policy and begin discharge documentation at the start of the care journey

Concerns raised1

Failure to assess patients and ensure medical and social factors are in place before discharge

Linked response

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

Concerns raised3

Failure to communicate required discharge-assessment factors to the assessor

Failure of assessment notes to clearly and accurately record information for the discharge decision-maker

Lack of clarity about required coverage in discharge assessments

Concerns raised1

Lack of discharge follow-up mechanisms for patients transferring to a different area

Linked response

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

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

Stated actions 2

Stated actions 2

Respondent positions 1

Respondent positions 1

Stated actions 3

Respondent positions 1