30 Jan 2014 Leslie Alfred Pates · Prevention of Future Deaths report Manchester South
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Concerns raised 4
Failure to consider the family’s views before discharge planning and implementation View source Failure to hold the required pre-discharge meeting with the family View source Lack of a pressure-relieving mattress at discharge home View source
Discharge home with severe pressure sores View source See 1 more concern
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Tameside and Glossop Integrated Care NHS Foundation Trust
Develop a discharge checklist confirming MDT engagement with patients and families before discharge.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Provide patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Formulate complex care plans for all parties to agree before patients return home.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
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AI-generated summary
Leslie Alfred Pates · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider the family’s views before discharge planning and implementation
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient .
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge .
” Source location Leslie Alfred Pates · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to hold the required pre-discharge meeting with the family
Wider context from the report “5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place .
” Source location Leslie Alfred Pates · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a pressure-relieving mattress at discharge home
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress .
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge.
” Source location Leslie Alfred Pates · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge home with severe pressure sores
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge.
” Source location Leslie Alfred Pates · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a discharge checklist confirming MDT engagement with patients and families before discharge.
Verbatim wording from the response “To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are being taken.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.
Verbatim wording from the response “The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.
Verbatim wording from the response “To ensure the patients and families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken:” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formulate complex care plans for all parties to agree before patients return home.
Verbatim wording from the response “A complex care plan has been formulated for all parties to agree the patient is supported and fully ready for home.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.
Verbatim wording from the response “All plans of care for patients must be shared with the patient and, with patient’s consent, their next of kin and agreed before discharge.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
Verbatim wording from the response “All patients returning home with care package will have their equipment needs assessed and documented in hospital.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
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23 Jan 2014 DESGRAE REGINA TUCKER · Prevention of Future Deaths report Gwent
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Concerns raised 2
Failure to prescribe anti-coagulant medication on discharge View source Failure to consider discharge home with anti-embolic stockings View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
DESGRAE REGINA TUCKER · 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
Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to prescribe anti-coagulant medication on discharge
Wider context from the report “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed.
(2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings.
(3) No anti-coagulant medication prescribed to the patient upon discharge .
” Source location DESGRAE REGINA TUCKER · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider discharge home with anti-embolic stockings
Wider context from the report “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed.
(2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings .
(3) No anti-coagulant medication prescribed to the patient upon discharge.
” Source location DESGRAE REGINA TUCKER · Prevention of Future Deaths report
Open source report
14 Jan 2014 John Joseph Malone · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of discharge documentation to include vital admission and discharge information View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John Joseph Malone · 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
John Joseph Malone suffered two falls at home, the second on 24 October 2013, which led to a subdural haematoma; the inquest concluded that he died an accidental death. Concern was raised that the hospital discharge letter was woefully short on detail and omitted vital information for his GPs, and that he fell within three days of discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of discharge documentation to include vital admission and discharge information
Wider context from the report “I took evidence from the two GP's caring for the deceased and they showed to me, inter alia, a discharge letter from your hospital dated 21st October 2013 a copy of which I append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's . On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date . The patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage.
” Source location John Joseph Malone · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure of surgical teams to maintain ongoing oversight after discharge View source Lack of a discharge plan for possible pelvic infection View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Keith Fleming · 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
Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of surgical teams to maintain ongoing oversight after discharge
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” Source location Keith Fleming · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a discharge plan for possible pelvic infection
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” Source location Keith Fleming · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to notify Social Services of discharge contrary to their recommendations View source
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.
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AI-generated summary
ROSEMARY BRONWYN FERGUSON · 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
ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to notify Social Services of discharge contrary to their recommendations
Wider context from the report “(1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to them.
” Source location ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Open source report
3 Dec 2013 Horace Cottom · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to provide prison healthcare professionals with timely and complete discharge information View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Horace Cottom · 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
Horace Cottom, a serving prisoner at HMP Manchester, died there on 21 June 2012 from pneumonia and heart disease with pseudomembranous colitis, with the inquest concluding that the death was from natural causes. The principal concern was that discharge information from NHS hospitals could take about 10 days to reach the prison and was sometimes incomplete, affecting the timely management of prisoners’ healthcare after hospital discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide prison healthcare professionals with timely and complete discharge information
Wider context from the report “However, the inquest did establish that following his last discharge, it took about 10 days for any discharge information/report to be received at the prison from the NHS hospital . Further enquiries revealed that this was quite common and locally in Manchester the prison service tried to get the discharging doctor to write out in manuscript form discharge information. This is not always successful and results in delay, as well as incomplete discharge information.
Recently, HMPS changed from using the NHS EMIS GP recording system and introduced what is known as 'System One'. This means that it is certainly easier for a prisoner who moves within the HMPS estate to have their GP records accessed immediately within the prison system.
Locally in Manchester, they also try to use an email system to collect discharge information, but this is not without problems itself. From what I was told at the inquest, it seems that some NHS information can be transmitted directly onto the System One, but for some reason discharge information is not sent.
HMPS caters for an increasing number of older prisoners with chronic health problems who have to attend outside NHS hospitals for investigations and treatment. It is vital that the healthcare professionals in prison have timely and full discharge information so that they can manage the care of the patient prisoner once they are returned to custody. One would hope that there is a simple and user-friendly way in which discharge information could be relayed to all prison healthcare establishments via the NHS. Whilst this has been highlighted as a local issue, I anticipate that it actually will be replicated nationwide. Accordingly, I am writing this letter under paragraph 37 & 38 of the enclosed Chief Coroner's Guidance No. 5 to bring this to your attention.
I appreciate that it will involve a number of others who can assist in resolving the position and therefore I am also going to send a copy of this letter to the Chief Executive of the NHS, the Minister for Prisons, the Director General of HMPS, the Governor of HMP Manchester, as well as the Medical Directors of the major NHS Trusts in Greater Manchester. I sincerely hope a solution can be found.
” Source location Horace Cottom · Prevention of Future Deaths report
Open source report
17 Oct 2013 Rosa ANDERSON · Prevention of Future Deaths report Liverpool
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Concerns raised 1
Failure to provide a discharge summary View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rosa ANDERSON · 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
Rosa Anderson underwent laparoscopic repair of a diaphragmatic hernia, during which her oesophagus was inadvertently damaged. The resulting mediastinitis compromised her breathing and led to cardiac arrest and hypoxic brain injury; concerns included that she was discharged without a discharge summary, written information about the operation, advice contact numbers, or warnings about when to seek urgent medical assistance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a discharge summary
Wider context from the report “During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30th April 2013 . Further, she was given no written information about her recent laparoscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance.
” Source location Rosa ANDERSON · Prevention of Future Deaths report
Open source report
Concerns raised 1
Delays in receiving and reviewing hospital discharge summaries View source
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.
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AI-generated summary
James Edward Mansfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in receiving and reviewing hospital discharge summaries
Wider context from the report “(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that the hospital post discharge letters to your surgery. This was not received until 28th February 2013 by which time Mrs Mansfield had called requesting stronger pain killers. The discharge summary was only reviewed by a doctor on 6 March . You stated that only if a patient was admitted to hospital would their discharge letter get prompt attention . There was no apparent method for differentiating between discharge summaries which involved serious injuries and those which did not.
” Source location James Edward Mansfield · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to notify family members of discharge where family support is relevant to safety View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Linda Hudson · 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
Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to notify family members of discharge where family support is relevant to safety
Wider context from the report “(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided.
” Source location Linda Hudson · Prevention of Future Deaths report
Open source report
17 Sep 2013 Alva JULLIEN · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to make a discharge decision View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Alva JULLIEN · 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
Alva Jullien was admitted to hospital after a fall at home but remained there without a home assessment despite being considered medically fit for discharge. During her hospital stay she became recumbent and developed pneumonia; the inquest conclusion stated that missed opportunities during her care might have optimised her chances of survival. The principal concerns were communication and decision-making failures affecting discharge, and the decision to make her nil by mouth and place her on the Liverpool Care Pathway with, in the coroner’s view, insufficient evidence.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make a discharge decision
Wider context from the report “There was clear evidence at the Inquest that ████████ daughter of the deceased, was not only able but willing to look after her mother in the home environment had her mother been discharged and it seemed clear to me from the evidence on a balance of probabilities that the deceased might well have survived had she have been discharged from hospital much earlier and that this discharge did not take place simply because of a lack of communication between the various health professionals and the want of a decision for discharge being taken .
” Source location Alva JULLIEN · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.