25 Jun 2024 John Howe · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to communicate changes in discharge timings to the ambulance service View source Failure to discharge patients within the required timing when they are unable to manage independently at home View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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John Howe · Prevention of Future Deaths report
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Report summary
John Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.
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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 communicate changes in discharge timings to the ambulance service
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings .
” Source location John Howe · Prevention of Future Deaths report
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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 discharge patients within the required timing when they are unable to manage independently at home
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening . In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings.
” Source location John Howe · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and progress the Out of Hours Discharge Avoidance SOP through MRI governance ratification for operational use.
Verbatim wording from the response “The MRI team have confirmed that a formal process for managing delayed discharges has now been developed via an “Out of Hours Discharge Avoidance” Standard Operating Procedure (SOP), which will be utilised as part of the operational application of the MFT Discharge Policy. Whilst this SOP is still in draft, it is due to be presented for ratification at the MRI Quality and Safety Committee on Tuesday 13th August 2024. For completeness a copy of the draft SOP has been enclosed within this correspondence.” Source location Response from MFT
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the draft Out of Hours Discharge Avoidance SOP with Wythenshawe Hospital and North Manchester General Hospital teams.
Verbatim wording from the response “MFT comprises of several adult hospital sites, and ambulance transport services are utilized across the organisation. The draft SOP has therefore also been shared with the teams at Wythenshawe Hospital and North Manchester General Hospital who have confirmed their intention to take it through their relevant governance structures to ratify and implement. I anticipate that this will prevent inconsistencies in discharge practices across the organisation, which could have led to challenges for external providers.” Source location Response from MFT
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ward contact before evening discharges will safeguard patients until the hospital’s discharge policy is received.
Verbatim wording from the response “During the Inquest, it was ascertained that discharges for patients on the wards at Manchester Royal Infirmary now have a cut off time at 21.00 hours for discharge from a hospital ward. At the time of the Inquest EMAS was not aware of this. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue to act as a safeguard to patients until the policy is received from Manchester Royal Infirmary.” Source location Response from EMAS
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PFD Monitor interpretation The second concern relates to Manchester City Council, so MFT will not provide a response.
Verbatim wording from the response “MFT was notified of the second concern outlined within the Regulation 28 report issued following the inquest, we understand that this relates to Manchester City Council and therefore no response is required from MFT on this matter.” Source location Response from MFT
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19 Jun 2024 Thomas Gibson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to audit the sufficiency of detail in discharge summaries View source
This report raised 6 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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Thomas Gibson · 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 Gibson was found dead at home on 7 June 2023, with the death attributed to sudden cardiac death due to idiopathic myocardial fibrosis. Eleven days earlier, two ECGs were not recognised as showing complete heart block, and he was discharged from hospital. Concerns included inadequate communication and contextual review of test results, lack of senior review when findings were unexpected, insufficient auditing of ECG interpretation and discharge summaries, and the absence of authoritative national guidance on ECG use and interpretation.
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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 audit the sufficiency of detail in discharge summaries
Wider context from the report “6. It is a matter of concern that no audit as to the sufficiency of detail contained in discharge summaries appears to have been undertaken to date in the light of the issues identified by the Trust’s High Impact Learning Assessment.
” Source location Thomas Gibson · Prevention of Future Deaths report
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10 Jun 2024 Margaret Ann PILGRIM · Prevention of Future Deaths report Essex
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Concerns raised 2
Failure to provide pain relief and consider a care package at discharge View source Failure to communicate identified fractures in discharge information View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Margaret Ann PILGRIM · Prevention of Future Deaths report
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Report summary
Margaret Ann Pilgrim died at Princess Alexandra Hospital on 29 June 2023 from congestive cardiac failure and bronchopneumonia, against a background of frailty, after an unwitnessed fall at home caused a fractured clavicle. The fracture was reported on an X-ray during her hospital admission but was not noted on her discharge summary. Concerns included the absence of treatment, pain relief, care-package consideration and fracture-clinic follow-up, and the failure to inform the patient, her family or GP about the fracture.
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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 pain relief and consider a care package at discharge
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” Source location Margaret Ann PILGRIM · Prevention of Future Deaths report
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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 communicate identified fractures in discharge information
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” Source location Margaret Ann PILGRIM · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
Verbatim wording from the response “- Aside from when the patient was initially admitted there was no reference to the patient complaining of pain in her shoulder by either the medical team or the therapists who” Source location Response from Princess Alexandra Hospital
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How this respondent position was interpreted
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PFD Monitor interpretation A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
Verbatim wording from the response “- The patient was advised to stay in the ED overnight in order to be seen by the REACT (Rapid Emergency Assessment Care Team) prior to her discharge so that she could be assessed for a potential package of care. Their assessment was that at the time she did not meet the threshold for this however some additional equipment was provided and ordered for her.” Source location Response from Princess Alexandra Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
Open published response
Concerns raised 2
Failure to ensure a robust safety plan upon discharge View source Failure to determine whether discharge or step-down should be delayed until a place of safety is identified View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
County Durham and Darlington NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust
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Andrew James Naylor · 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
Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his death.
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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 ensure a robust safety plan upon discharge
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge .
” Source location Andrew James Naylor · Prevention of Future Deaths report
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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 determine whether discharge or step-down should be delayed until a place of safety is identified
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge , and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified , and to ensure that a robust safety plan is in place upon discharge.
” Source location Andrew James Naylor · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical review, discharge documentation and policy-based follow-up arrangements were considered sufficient to address discharge safety concerns.
Verbatim wording from the response “Mr Naylor was reviewed by liaison psychiatry on the ward prior to discharge and it was documented by the team as being under the care of the community mental health team, who liaison psychiatry would request follow up by, and that he was safe for discharge. In relation to post discharge care, the Management of Acute Alcohol Withdrawal Policy details the follow up that should occur for the patients such as Mr Naylor, including referral on to specialist drug and alcohol teams and services and there was a plan for him to be followed up by the alcohol liaison service post discharge. In relation to his residential status, this was consistently documented as being in a named hostel during his admission.” Source location Response from CDDFT
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PFD Monitor interpretation Discharge need not normally be delayed for homeless patients when capacity, medical and mental-health fitness, signposting, and community support are in place.
Verbatim wording from the response “4. Discharge arrangements.
As we described to HMAC, the experience of the Liaison team working within CDDFT is that discharge would not usually be delayed for a homeless patient, in circumstances where the patient (1) has capacity, (2) is medically optimised and deemed fit for discharge, (3) is considered fit for discharge following review by the mental health liaison team, (4) has been appropriately signposted to the Local Authority regarding homelessness, and (5) has support in place in the community from the Community Mental Health Team as well as Drug and Alcohol services. Clearly, it is imperative that capacious, homeless patients who are fit for discharge, are given the correct advice, signposting and support around homelessness, but in our experience, this does not mean remaining as an inpatient until accommodation arrangements have been secured.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
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17 May 2024 Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1
Failure of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report
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Report summary
Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.
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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 hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors
Wider context from the report “(3) Where repeat prescriptions were issued on discharge of a patient from hospital back
to community primary care, there was no warning on the discharge documentation
to alert the prescriber to the considerations and risk factors in the prescription of
NSAIDs (including the use of PPI).
” Source location Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
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14 May 2024 Carol Ann DIVALL · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Failure to provide accurate and complete discharge information View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Sussex Healthcare NHS 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. 5
East Sussex Healthcare NHS Trust
Develop and implement the 5P discharge process for communicating significant pressure damage.
View source
East Sussex Healthcare NHS Trust
Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
View source
East Sussex Healthcare NHS Trust
Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
View source
East Sussex Healthcare NHS Trust
Share the end-of-life recognition flow chart throughout the hospitals after piloting.
View source
East Sussex Healthcare NHS Trust
Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
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Carol Ann DIVALL · Prevention of Future Deaths report
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Report summary
Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.
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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 accurate and complete discharge information
Wider context from the report “D. The Discharge Summary was misleading to the District Nurses who were unaware of the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did not make clear that Mrs Divall had been discharged for end of life care .
” Source location Carol Ann DIVALL · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the 5P discharge process for communicating significant pressure damage.
Verbatim wording from the response “The Chief Nurse has proposed a new process called the ‘5P Process for Discharge’ to improve the communication related to significant pressure damage on discharge. This has been presented and discussed at length with senior nurses across the organisation and is currently being developed and implemented. The process includes utilising our medical illustration team to take clear images of wounds for sharing with carers with consent as required. We have included a copy of the process as Attachment A, and a copy of the 5P slide deck at Attachment B.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Verbatim wording from the response “To address these information concerns, we have developed a flow chart on how to refer to District Nurses and what information needs to be shared to support decision making and tasks related to fast track discharge, available on the extranet and in the discharge policy.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
Verbatim wording from the response “By applying this approach to the care delivered to Mrs Divall the Trust acknowledge and accept the concerns of the Coroner. We are aware we need to review and improve our communication with next of kin and, as above, between teams on discharge such as the District Nurses and ward to ensure important information is cascaded avoiding confusion and distress to families. We now have bimonthly Quality Summits which all the Ward Matrons will be attending in person to emphasise the importance of communication between families but also between staff in order to ensure that care provided is of the highest quality. We have also developed quality documentation audits and discharge checklist audits so that where we see a miscommunication we can put it right in the moment.” Source location Response from East Sussex Healthcare
Open published response
Concerns raised 1
Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Department of Health and Social Care
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Sally Poynton · Prevention of Future Deaths report
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Report summary
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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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 Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Source location Sally Poynton · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board is expected to respond to concerns about the specific care provided.
Verbatim wording from the response “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.” Source location 2024-0267 Response from Department of Health and Social Care
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2 May 2024 Karen THOMASON · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to notify support services of vulnerable patients' discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Karen THOMASON · 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
Karen Thomason, aged 52, collapsed at home on 31 October 2023, was discharged from hospital without Cumbria Housing staff being notified, and was found unresponsive at home the following day. Her death was confirmed on 1 November 2023 after she had consumed a substantial amount of alcohol. The concerns included errors in safeguarding documentation, failures to notify housing staff about discharge, and the risk of conflating capacity with an absence of vulnerability or safeguarding concerns.
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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 support services of vulnerable patients' discharge
Wider context from the report “(2) There is evidence that Cumbria Housing staff had asked to be notified of the discharge of a vulnerable patient so that they could provide support to her but that they received no communications on several occasions. I am concerned that this may mean that other patients are discharged without appropriate support being alerted to their needs .
” Source location Karen THOMASON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Verbatim wording from the response “RECOMMENDATION 2: Update Symphony to include discharge discussions for all patients. Include an ask “is there anything we can do or anyone we can notify before you go home?” Explore the “discharge screen” options on symphony to include a vulnerable adult question set.” Source location Response from North Cumbria Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Verbatim wording from the response “Unfortunately, the ED Team were not made aware at any stage during Ms Thomason’s ED attendance, of any ask or requirement to notify the Housing Officer of Ms Thomason discharge or that the Housing officer had any concerns, either by the Housing Officer themselves, the Ambulance Service, or Ms Thomason. This was not conveyed verbally nor was it documented in the Ambulance records that were shared with ED on Ms Thomason’s arrival into the department.” Source location Response from North Cumbria Integrated Care
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25 Apr 2024 Richard Carpenter · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Lack of appropriate community care packages for patients fit for discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Richard Carpenter · 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
Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of appropriate community care packages for patients fit for discharge
Wider context from the report “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community . This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion.
” Source location Richard Carpenter · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.
Verbatim wording from the response “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a £40 million fund for local authorities facing significant urgent and emergency care pressures.
Verbatim wording from the response “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.” Source location Response from Department of Health and Social Care
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17 Apr 2024 Margaret Avril Burman · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Lack of appropriate community care causing medically fit patients to remain on hospital wards View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Margaret Avril Burman · 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 Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of appropriate community care causing medically fit patients to remain on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards . The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures.
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” Source location Margaret Avril Burman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.
Verbatim wording from the response “Your Report also raises a concern around patients medically fit for discharge are remaining in hospital due to a lack of appropriate community care being available. This remains a challenge for the NHS and social care services across England. As a key part of NHS England’s Urgent & Emergency Care recovery, NHS England together with colleagues across the DHSC and the Department for Levelling up, Housing and Communities (DLUHC) are focussed on improving discharge processes and capacity modelling to ensure the right number of commissioned beds/non-bedded care.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.
Verbatim wording from the response “A range of programmes aimed at improving both admissions avoidance and discharge flow is being undertaken to support the reduction in the number of patients in acute medical beds with no criteria to reside. This work is a key priority for the NHS and is being driven through the published NHS Operational Planning Guidance and the Better Care Fund planning process and has associated improvement support available to regions and local systems.” Source location Response from NHS England
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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 responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
Verbatim wording from the response “I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.” Source location Response from DHSC
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.