19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Reliance of delayed-discharge protocols on home-team engagement View source
This report raised 8 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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Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.
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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 Reliance of delayed-discharge protocols on home-team engagement
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate. However, it relies on the ‘home team’s’ engagement in the process .
” Source location Lauren Elizabeth Bridges · Prevention of Future Deaths report
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15 Sep 2023 Geoffrey Robin Brooks · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Failure of discharge summaries to clearly communicate target fluid intake View source
Linked response
Royal Devon University Healthcare 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. 7
Royal Devon University Healthcare NHS Foundation Trust
Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
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Royal Devon University Healthcare NHS Foundation Trust
Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
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Royal Devon University Healthcare NHS Foundation Trust
Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
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Royal Devon University Healthcare NHS Foundation Trust
Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
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Royal Devon University Healthcare NHS Foundation Trust
Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
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Royal Devon University Healthcare NHS Foundation Trust
Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
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Royal Devon University Healthcare NHS Foundation Trust
Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
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Geoffrey Robin Brooks · 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
Geoffrey Robin Brooks, who had nephrogenic diabetes insipidus, was admitted to hospital in October 2020 after his health deteriorated and died on 12 November 2020 despite treatment. The discharge summary did not clearly state that his required fluid intake of 2.5 to 3 litres per day was a target, and the target was not met while he was in the nursing home; the inquest concluded that he died from complications of nephrogenic diabetes insipidus on a background of poor fluid intake.
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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 summaries to clearly communicate target fluid intake
Wider context from the report “During his evidence the consultant physician with the responsibility for the care and treatment of Mr Brooks acknowledged that the discharge summary was ambiguous and did not make it clear that the 2.5 – 3L was a target fluid intake ; he agreed that it could be interpreted that Mr Brooks should be restricted to no more than 2.5 to 3L of fluid a day . As a consequence, the nursing home staff were unaware of the needs of Mr Brooks . The target fluid intake was not met in the period that Mr Brooks was in the nursing home, which contributed to his death.
” Source location Geoffrey Robin Brooks · Prevention of Future Deaths 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 Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
Verbatim wording from the response “The RDUH switched to an electronic patient record (Epic) across its Eastern services in October 2020, which was after the date of this incident. This has led to significant improvements in documentation across inpatient and outpatient encounters. Epic has several features that help improve documentation specifically around discharge:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
Verbatim wording from the response “2. Bespoke templated discharge summaries
Some areas (e.g. Stroke, Acute Care of the Elderly) have specific templates for completing discharge letters which ensures pertinent information and ongoing instructions are as clear as possible. This is important for more complex patient groups who need to have specific assessments and follow-up.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
Verbatim wording from the response “5. Enhanced ward staffing consistency
Within Medicine, our staffing model was changed recently so that junior doctors in training have switched to a 4-day working week. Previously, compensatory rest meant that juniors were often moved from their base wards to cover rota gaps; this led to a loss of consistency in medical staffing which is a risk to discharge letters writing as discussed above. The new rota pattern means the need for cross cover is greatly reduced.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
Verbatim wording from the response “3. After Visit Summary
Epic has introduced the ability to generate a patient focused document for inpatient and outpatient attendances - the After Visit Summary (AVS) which can be given to patients at the point of hospital discharge. To date, the AVS has not been widely rolled out, particularly after inpatient stays.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
Verbatim wording from the response “A working group has been established and will shortly begin meeting to review the use of the AVS across inpatient and outpatient areas across the Trust. Once completed, the group will produce new guidance and Standard Operating Procedures (SOPs) for ward teams, meaning the AVS would be given to the patient and the discharge summary sent electronically to the GP as a matter of routine. It clearly lays out medication changes, follow-up arrangements and can be used to provide patient’s with specific instructions. In this case, clear documentation of fluid intake requirements could have been flagged in this document.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
Verbatim wording from the response “We are currently reviewing the staffing model of our community hospitals which we hope will lead to a more robust, consistent medical team with specialty doctor and Advanced Clinical Practitioner oversight. This will provide an additional safety-net around discharge and again letters will be more likely to be written and checked by individuals who have reliably been involved in a patient’s care.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
Verbatim wording from the response “The Trust wide discharge summary working group will be shortly relaunched with a plan to have primary care representation to try and further refine discharge processes and communication with primary care. There is potential to develop more discharge summary templates for specific specialties or conditions. We are continually working on improving the completion rates of discharge summaries and ensuring they are sent in accordance with the NHS Standard Contract agreement of within 24 hours following inpatient, day case or ED attendance.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Trust considers reviewing every discharge letter by a consultant infeasible because of resource demands, unclear responsibility, delays and risks of error.
Verbatim wording from the response “Other considerations
The Trust has considered whether every discharge letter should be reviewed by a consultant. On balance, this would not seem feasible due to:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised 2
Inconsistency between hospital and community teams about post-discharge procedures and points of access View source Absence of documented discharge advice on points of access for concerns or complications View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Gateshead Health NHS Foundation Trust the Newcastle Upon Tyne Hospitals 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
Gateshead Health NHS Foundation Trust
Liaise with Newcastle Trust to confirm the correct procedure for community teams to contact vascular services about post-discharge concerns.
View source
Gateshead Health NHS Foundation Trust
Share inquest findings with District Nurses, reiterating ward contact routes, contact-information access, and warning signs after femoral endarterectomy.
View source
Gateshead Health NHS Foundation Trust
Develop a professional information leaflet for District Nurses covering post-operative risks, escalation requirements, and intervention following femoral endarterectomy.
View source
the Newcastle Upon Tyne Hospitals NHS Foundation Trust
Provide patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.
View source
the Newcastle Upon Tyne Hospitals NHS Foundation Trust
Operate a 24-hour vascular call-triage pathway directing wound concerns to specialist nurses or the on-call vascular registrar.
View source
the Newcastle Upon Tyne Hospitals NHS Foundation Trust
Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.
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William Nichols · 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
William Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team record keeping.
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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 Inconsistency between hospital and community teams about post-discharge procedures and points of access
Wider context from the report “(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).
” Source location William Nichols · 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 Absence of documented discharge advice on points of access for concerns or complications
Wider context from the report “(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).
” Source location William Nichols · 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 Liaise with Newcastle Trust to confirm the correct procedure for community teams to contact vascular services about post-discharge concerns.
Verbatim wording from the response “As heard at the inquest and in our subsequent submissions made by letter in July 2023, the Trust followed the correct procedure of contacting the ward at the Newcastle Trust, when the Community team noted the presence of fresh blood and spoke with a Specialist Vascular Nurse from the Newcastle Trust for advice, who in turn spoke with a medic from the Vascular Team. Following the inquest, the Trust liaised with the Newcastle Trust, to ensure that this remains the correct procedure for contacting their team and they have confirmed it does.” Source location Response from Gateshead Health NHS Foundation Trust
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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 inquest findings with District Nurses, reiterating ward contact routes, contact-information access, and warning signs after femoral endarterectomy.
Verbatim wording from the response “Following the inquest and collaboration with the Newcastle Trust, the findings of the inquest have been shared with our District Nurses, to reiterate the process they already follow, including:” Source location Response from Gateshead Health NHS Foundation Trust
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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 professional information leaflet for District Nurses covering post-operative risks, escalation requirements, and intervention following femoral endarterectomy.
Verbatim wording from the response “We have also been liaising with the Newcastle Trust and developed a professional information leaflet for District Nurses which outlines what they should be aware of in relation to this specific procedure in the post operative period and what requires escalation and intervention. We understand you have received this from Newcastle Trust. We have therefore done all we can as a Trust in relation to this concern.” Source location Response from Gateshead Health NHS Foundation Trust
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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 community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.
Verbatim wording from the response “Patients in advance of admission to hospital for their surgery are to be provided with a Femoral Endarterectomy Patient Information Leaflet providing full explanation of their pathology along with the proposed surgery, post operative course and potential complications. The course of action to be taken by patient, community nursing team or GP being provided with the relevant contact points along with phone number to call (see Appendix 1). This is in addition to providing the same information to the patient on discharge in a leaflet Wound care following arterial surgery (see Appendix 2) and in written communication in the discharge summary headed as “Information to Patient” (see Appendix 3).” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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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 Operate a 24-hour vascular call-triage pathway directing wound concerns to specialist nurses or the on-call vascular registrar.
Verbatim wording from the response “• If patients call the ward with a concern about their wound during normal working hours, the ward will direct the call to the specialist vascular nursing team, for their initial advice.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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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 Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.
Verbatim wording from the response “• Calls from patients about their wounds and the advice given to them should be documented as an entry on e-Records by either the specialist nursing team, or the on-call vascular registrar (or both if they are both involved in the advice), and this entry should be made as close to the time of the call as possible.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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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 procedures and collaboration with Newcastle Trust adequately address post-discharge communication and escalation following vascular surgery.
Verbatim wording from the response “It is the Trust's position that we have already addressed this concern (and had done so by the time of the inquest hearing) and therefore it is unclear if this concern is directed at us, but in the event that it is, we would respond as follows.” Source location Response from Gateshead Health NHS Foundation Trust
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19 Jul 2023 Carole MCQUINN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 3
Failure to provide discharge medications View source Lack of discharge notes View source Safety hazard associated with evening hospital discharges View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leeds Teaching Hospitals NHS Trust York and Scarborough Teaching Hospitals 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. 5
Leeds Teaching Hospitals NHS Trust
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
View source
Leeds Teaching Hospitals NHS Trust
Amend the electronic discharge-note template to include required discharge information and advice.
View source
York and Scarborough Teaching Hospitals NHS Foundation Trust
Update and disseminate clinical record-keeping guidance to clinical staff.
View source
Leeds Teaching Hospitals NHS Trust
Disseminate discharge-advice guidance and train registered nurses in its use.
View source
Leeds Teaching Hospitals NHS Trust
Operate a quality-improvement collaborative supporting earlier ward discharges and monthly tracking of discharge performance and EDAN provision.
View source See 2 more actions
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Carole MCQUINN · 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
Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.
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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 discharge medications
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” Source location Carole MCQUINN · 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 discharge notes
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note , medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” Source location Carole MCQUINN · 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 Safety hazard associated with evening hospital discharges
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself , and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” Source location Carole MCQUINN · Prevention of Future Deaths 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 Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Verbatim wording from the response “Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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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 Amend the electronic discharge-note template to include required discharge information and advice.
Verbatim wording from the response “Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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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 Update and disseminate clinical record-keeping guidance to clinical staff.
Verbatim wording from the response “On review of this matter it became apparent that the Trust’s clinical record-keeping guidance was out of date. This was already on the work plan to be updated and will now be expedited. Once the guidance is finalised it will be shared with all clinical staff.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
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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 Disseminate discharge-advice guidance and train registered nurses in its use.
Verbatim wording from the response “Following the hearing and in response to your report the CSU has reviewed the steps taken to improve discharging practice and it has drafted Good Practice Guidance for the completion of discharge advice notes by registered nurses (please see attachment 2). Dissemination of this guidance, with training for staff, will be complete by the end of October 2023. Support to embed good practice will also be provided by the CSU quality practitioners and the clinical education team by the end of November 2023. The guidance has already been discussed with the nursing staff at the CSU Perfect Ward meeting (where all matrons and ward sisters meet each month to review all quality indicators and incidents within the CSU) and ward sisters are now sharing it with their staff in each ward area.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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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 Operate a quality-improvement collaborative supporting earlier ward discharges and monthly tracking of discharge performance and EDAN provision.
Verbatim wording from the response “The Trust recognises the difficulties that can arise when patients leave hospital late on the day of discharge and it is committed to improving discharging practice throughout the organisation. A Quality Improvement collaborative led by a specialist quality improvement practitioner is in place to support wards to achieve the majority of discharges before 3pm. By using data and metrics the Trust can track all wards’ progress towards this target each month and it can also check that EDANs have been sent with patients at the point of discharge. AMS CSU is part of this collaborative and it will continue to work to improve its practice.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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16 Jun 2023 Girmaye Guyo Liban · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Lack of a thorough procedure or legal test for assessing nearest relative discharge applications 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
Girmaye Guyo Liban · 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
Girmaye Guyo Liban had a long history of mental health illness and substance abuse, was discharged from detention under the Mental Health Act 1983, remained unwell in the community, went missing on 10 November 2020, and his body was found in a reservoir on 26 November 2020. The concern was that the Nearest Relative Power could enable discharge despite a patient continuing to meet the criteria for detention, without a thorough procedure or legal test for clinicians to apply.
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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 Lack of a thorough procedure or legal test for assessing nearest relative discharge applications
Wider context from the report “The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention. There does not appear to be a thorough procedure or legal test for clinicians to apply , and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention .
” Source location Girmaye Guyo Liban · Prevention of Future Deaths report
Open source report
9 Jun 2023 Alice Jean FOX · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Lack of protocols ensuring safe and appropriate multi-party discharge arrangements View source
This report raised 5 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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Alice Jean FOX · 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
Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.
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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 Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate .
” Source location Alice Jean FOX · Prevention of Future Deaths report
Open source report
7 Jun 2023 Brenda SHIELDS · Prevention of Future Deaths report Cumbria
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Concerns raised 3
Failure to involve family or carers in discharge processes View source Failure to plan follow-up after discharge View source Delays in sending discharge notifications to GPs View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cumbria, Northumberland, Tyne and Wear 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. 2
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Monitor caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.
View source
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.
View source
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Brenda SHIELDS · 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
Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.
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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 involve family or carers in discharge processes
Wider context from the report “(3) I refer you to the PFD report I issued referring to Charlotte Grace on 29/10/19. Assurances were given in response to that report which again focused on discharge without family/carer involvement which is surely paramount . I note actions mentioned in the incident report in this case but am still concerned that similar events may occur in future .
” Source location Brenda SHIELDS · 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 plan follow-up after discharge
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” Source location Brenda SHIELDS · 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 Delays in sending discharge notifications to GPs
Wider context from the report “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death . Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.
” Source location Brenda SHIELDS · Prevention of Future Deaths 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 Monitor caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.
Verbatim wording from the response “Actions/Recommendations:” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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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 Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.
Verbatim wording from the response “Carer leads continue to roll out carer awareness training. This is at 80% across the service currently. A further 8 staff have had Carer Awareness and Getting To Know You training over the past 4 months. Carer leads also offer 1:1 Training for new staff working within CRHT.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
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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 investigation concluded that identified family-involvement issues were not causative or contributory to the death.
Verbatim wording from the response “We note that the extent to which the issues with family involvement in this case were not explored in evidence due to the absence of any Trust witnesses however, the written evidence from the SI investigation concluded that the findings/learning identified in this investigation were not considered to be causative or contributory to Brenda's death, particularly as carers' views had been sought at a number of points during Brenda's care and treatment and the Getting To Know You documentation had been completed.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
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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 discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Verbatim wording from the response “In addition to the above, this concern also suggests that Brenda was discharged from the Hadrian Unit and the Crisis Team without any planned follow up. Again, by way of clarification and in accordance with the written evidence provided, immediately following discharge from the Hadrian Unit, Brenda was supported in the community by the Cumbria East Crisis Team, and she continued to be supported by this service until the date of her sad death (on which date she was also discharged from the service). The role of crisis services is to provide people with safe, effective, compassionate, high-quality care whilst they remain in mental health crisis. Where appropriate and as in this case, the crisis service offers home treatment intervention to allow people to be discharged from hospital earlier whilst still experiencing an acute phase of illness.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Open published response
7 Jun 2023 David WOOD · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to plan discharge from hospital 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
David WOOD · 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
David Wood had recently undergone open heart surgery and was suffering from depression and difficulty sleeping after discharge from hospital. On 22 June 2022, he was found suspended by the neck at his home. A review identified concerns about communication of possible delirium to his GP and wife, discharge planning, and the protocols for discharge following heart surgery.
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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 plan discharge from hospital
Wider context from the report “Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance.
The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths.
” Source location David WOOD · 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 Provide a full-time heart-centre discharge coordinator using a multidisciplinary approach for discharge planning.
Verbatim wording from the response “2. If post-operative delirium occurs, considering involving an appropriate family member in discharge discussions (with the patient’s consent), to alert them as to what to expect in the process of recovery and when to seek further medical assistance after discharge.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
16 May 2023 Benedict Peters · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Manchester University NHS Foundation Trust
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AI-generated summary
Benedict Peters · 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
Benedict Peters was found dead at his parents’ home on 12 November 2022, after being discharged from the Manchester Royal Infirmary Ambulatory Care Unit the previous day following assessment for chest pain, shortness of breath, sore throat and an aching arm. The inquest found that he died from haemopericardium and acute aortic dissection, with a narrative conclusion referring to complications from an undiagnosed underlying heart defect. Concerns included his discharge without an in-person doctor’s review despite his symptoms, age and family history, and the absence of a Trust policy or protocol governing such discharges.
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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 conduct an in-person medical review before discharge from the Ambulatory Care Unit
Wider context from the report “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor .
It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place.
” Source location Benedict Peters · Prevention of Future Deaths report
Open source report
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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 Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.
Verbatim wording from the response “Mr Peters had been seen and assessed by a Physician Associate (PA), these are professional practitioners working under the aegis of the Royal College of Physicians of London which has produced guidance regarding their responsibilities and scope of practice (https://www.rcplondon.ac.uk/news/fact-finding-physician-associates). Within Manchester University NHS Foundation Trust (MFT), PAs work within an agreed governance framework (enclosed). This has the effect that PAs are not independent practitioners (paragraph 12.7) but work under the delegated authority of a consultant (paragraph 14.2). It is the responsibility of the supervising consultant to ensure that the level of supervision is appropriate to the knowledge and skills of each individual PA.” Source location Response from Manchester University NHS Foundation Trust
Open published response
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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 Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.
Verbatim wording from the response “2) “No policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place”” Source location Response from Manchester University NHS Foundation Trust
Open published response
Concerns raised 2
Failure to coordinate inpatient discharge with family and other agencies View source Failure of the care coordinator to establish direct contact and a relationship with the service user before discharge View source
This report raised 11 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
Odessa Carey · 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
Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.
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 coordinate inpatient discharge with family and other agencies
Wider context from the report “3. Inpatient discharge 30 May 2018
The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family , the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support
I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge.
I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust.
” Source location Odessa Carey · 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 of the care coordinator to establish direct contact and a relationship with the service user before discharge
Wider context from the report “3. Inpatient discharge 30 May 2018
The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family, the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support
I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge.
I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust.
” Source location Odessa Carey · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.