Recurring concern

Unreliable hospital discharge processes

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First reported 30 Jan 2013•Latest report 10 Jun 2026

Definition

What this concern includes

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

Not included

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

Reports: 273
Individual concerns: 406
Date range: 2013–2026
Stated actions: 524

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care48

NHS England20

University Hospitals Sussex NHS Foundation Trust9

Essex Partnership University NHS Foundation Trust8

Manchester University NHS Foundation Trust8

Barts Health NHS Trust7

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

NHS Greater Manchester Integrated Care Board6

Tameside and Glossop Integrated Care NHS Foundation Trust6

Betsi Cadwaladr University LHB5

Kent and Medway Mental Health NHS Trust5

Pennine Care NHS Foundation Trust5

Royal London Hospital5

Stockport NHS Foundation Trust5

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

30 Sep2022
East London
Concerns raised1
1. Failure to verify the most recent clinical observations and PEWS score before discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and use a two-hourly Paediatric SITREP to record, escalate and plan responses to staff concerns despite low PEWS.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Provide ongoing teaching on paediatric gastroenteritis risks, deterioration despite low PEWS and communicating concerns.
  Stated by Barts Health NHS TrustStated in progress
3. Action
  Auto-populate the latest clinical observations and blood results in records when clinicians make entries before discharge decisions.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Shahan Abu Aman · 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

Shahan Abu Aman, a three-year-old boy, attended hospital on 7 December 2021 with vomiting and diarrhoea and was discharged after assessment, observation and a fluid challenge. He was found unresponsive the following morning and died in hospital; the report identified miscommunication between nursing and medical staff, failure to confirm the most recent observations and PEWS score before discharge, and a pressurised emergency department environment as concerns.

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 verify the most recent clinical observations and PEWS score before discharge
Wider context from the report
“2. The doctor who authorised discharge did not satisfy himself of the most recent set of clinical observations and associated Paediatric Early Warning Sign (PEWS) score prior to discharge. ”
Source location
Shahan Abu Aman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement and use a two-hourly Paediatric SITREP to record, escalate and plan responses to staff concerns despite low PEWS.

Verbatim wording from the response
“The Paediatric Emergency Department has now implemented and is using a detailed 2 hourly SITREP (Situational Report). The SITREP aims to capture this exact concern from members of staff who are worried about a patient who, despite the psychological parameters being abnormal, the early warning score does not identify this concern.”

Source location
Response from Barts Health NHS
Page 2 · response
Published 10 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide ongoing teaching on paediatric gastroenteritis risks, deterioration despite low PEWS and communicating concerns.

Verbatim wording from the response
“also acknowledged. With this in mind, the evidence bundle which has already been provided, demonstrates all the teaching and educational efforts that we have put in place and continue to provide; highlighting the importance of this case. Within these teaching modalities, although not explicitly mentioned, the emphasis on communicating concerns remains a rolling theme.”

Source location
Response from Barts Health NHS
Page 3 · response
Published 10 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Auto-populate the latest clinical observations and blood results in records when clinicians make entries before discharge decisions.

Verbatim wording from the response
“This is a theme that was recognised before the inquest. In response, processes were put in place whereby the last set of observations and blood results over which a clinician makes an entry into the records, are auto-populated so that the clinician can be sighted on these. In this particular case the early warning score identified only 1 abnormal parameter which, according to National Guidance, does not merit repeated frequent observations. However, as mentioned above the department fully recognises that no system can be 100% sensitive and has put in a large amount of effort to ensure that the messaging/learning is shared that children presenting with gastroenteritis, despite low early warning scores, can be critically unwell. This educational programme has already been demonstrated in the evidence provided to the court.”

Source location
Response from Barts Health NHS
Page 3 · response
Published 10 October 2022
Open published response
4 Aug2022
Manchester South
Concerns raised1
1. Lack of specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Existing NHS, NICE and UKHSA guidance was considered sufficient to address COVID-19 infection prevention and expedited discharge concerns.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  CQC considered Trust assurances and ongoing monitoring sufficient, so it identified no need for further investigation of this specific case.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
2. Position
  The Trust's existing vulnerable-patient risk-management process, shared learning and discharge focus were considered sufficient responsive arrangements.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Malcolm John Garrett · 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

Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with severe back pain and subsequently developed pneumonia and Covid-19 while an inpatient. He deteriorated and died at Stepping Hill Hospital on 23 September 2021; post-mortem examination identified Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia as the direct causes of death. Concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting their discharge or using alternative treatment methods, and monitoring kidney function to reduce opiate toxicity.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients
Wider context from the report
“2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment; ”
Source location
Malcolm John Garrett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing NHS, NICE and UKHSA guidance was considered sufficient to address COVID-19 infection prevention and expedited discharge concerns.

Verbatim wording from the response
“You may wish to note that during the COVID-19 pandemic, extensive clinical guidance was issued by the NHS (eg. Coronavirus (england.nhs.uk) as well as by the National Institute for Health and Care Excellence (NICE), see Overview | COVID-19 rapid guideline: managing COVID-19 | Guidance | NICE. More broadly, UKHSA also issued guidance in relation to patient discharge and infection prevention and control in health and care settings.¹”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 31 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
CQC considered Trust assurances and ongoing monitoring sufficient, so it identified no need for further investigation of this specific case.

Verbatim wording from the response
“The CQC advised that the matters of concern in this case, namely, hospital acquired COVID-19 and deaths attributed to a failure in monitoring kidney function are subject to regular reporting and/or evaluation as part of CQC’s monitoring and engagement activity. A management review meeting held in August 2022 concluded that neither concern was reflected in the monitoring data CQC held in relation to this Trust, such as being an outlier for the management of kidney injury. The Trust was asked at the time to provide any records or investigation reports relating to the death which the CQC would consider as part of its ongoing monitoring and engagement to ensure patients receive safe care and treatment.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 31 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust's existing vulnerable-patient risk-management process, shared learning and discharge focus were considered sufficient responsive arrangements.

Verbatim wording from the response
“NHS England also engaged with the Trust and advised that the Trust has a process in place to manage and reduce the risks of patients in vulnerable groups. They further advised that the Trust has shared the learning from this incident and that it has continued to focus on patient discharge.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 31 May 2024
Open published response
4 Aug2022
Manchester South
Concerns raised1
1. Lack of specific guidance for expediting discharge of patients at high risk of acquiring Covid-19
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Malcolm John Garrett · 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

Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with a vertebral fracture and subsequently developed pneumonia and other complications. He acquired Covid-19 while an inpatient and died at Stepping Hill Hospital on 23 September 2021; the direct causes were Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia. The concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting discharge or using alternative treatment methods, and monitoring kidney function to avoid opiate toxicity.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of specific guidance for expediting discharge of patients at high risk of acquiring Covid-19
Wider context from the report
“2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment; ”
Source location
Malcolm John Garrett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Aug2022
Black Country
Concerns raised1
1. Failure to await blood test results before discharge
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
  Stated by the Royal Wolverhampton NHS TrustStated planned
2. Action
  Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
  Stated by the Royal Wolverhampton NHS TrustStated completed
3. Action
  Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
  Stated by the Royal Wolverhampton NHS TrustStated planned
1. Action
  Review and include the discharge blood-result process in ED policy and guidance.
  Stated by the Royal Wolverhampton NHS TrustStated planned
AI-generated summary

Mrs Rita Flynn · 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

Mrs Rita Flynn became ill with flu-like symptoms and was assessed by her GP and New Cross Hospital. Her condition deteriorated, with shortness of breath and haemoptysis, and she was discharged home before blood-test results indicating infection were available; she died at home on 4 February 2022. The inquest found that she died after complications arising from a lung abscess, and the concern identified was that it would have been best practice to wait for the blood-test results before discharge.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to await blood test results before discharge
Wider context from the report
“1. Evidence emerged during the inquest that there were clear indicators of an infection and before being discharged home by the hospital, it would have been best practice to wait for the blood tests results. ”
Source location
Mrs Rita Flynn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.

Verbatim wording from the response
“There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level.”

Source location
Response from The Royal Wolverhampton
Page 2 · response
Published 10 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.

Verbatim wording from the response
“An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.”

Source location
Response from The Royal Wolverhampton
Page 2 · response
Published 10 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.

Verbatim wording from the response
“Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours).”

Source location
Response from The Royal Wolverhampton
Page 2 · response
Published 10 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and include the discharge blood-result process in ED policy and guidance.

Verbatim wording from the response
“1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.”

Source location
Response from The Royal Wolverhampton
Page 1 · response
Published 10 October 2022
Open published response
1 Jul2022
East London
Concerns raised1
1. Failure to consider and act on dangerously elevated creatinine results before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Pilot a dedicated process for immediate VBG result sign-off, clinician review, ECG signing and resulting actions.
  Stated by Barts Health NHS TrustStated in progress
2. Action
  Evaluate the VBG process and additional resources using quality improvement methodology.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Examine whether electronic patient records can track VBGs and provide an audit trail and completion alert.
  Stated by Barts Health NHS TrustStated in progress
1. Action
  Brief staff to perform three safety checks of results at availability, referral or movement to SDEC, and discharge.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Daniel Xavier · 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

Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.

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 consider and act on dangerously elevated creatinine results before discharge
Wider context from the report
“1. Prior to Mr Xavier’s discharge from hospital on the evening of 21st October 2021, the deceased’s venous blood gas results were not considered and acted upon by staff. The results, available from 13.17, indicated that Mr Xavier had a dangerously elevated creatinine level. Evidence heard at inquest indicated that had the results been considered, Mr Xavier would not have been discharged, he would have been escalated to the resuscitation department. Further, the Trust accepted that had the creatinine levels been acted upon, it is likely that the outcome for Mr Xavier could have been different. ”
Source location
Daniel Xavier · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Pilot a dedicated process for immediate VBG result sign-off, clinician review, ECG signing and resulting actions.

Verbatim wording from the response
“In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.”

Source location
Response from Barts Health NHS
Page 1 · response
Published 23 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Evaluate the VBG process and additional resources using quality improvement methodology.

Verbatim wording from the response
“In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.”

Source location
Response from Barts Health NHS
Page 1 · response
Published 23 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Examine whether electronic patient records can track VBGs and provide an audit trail and completion alert.

Verbatim wording from the response
“In the medium term, the department is examining whether VBGs can be tracked on the electronic patient records system in the same way as happens with ECGs. This would have the additional benefit of providing a more robust audit trail than paper and giving an immediate alert that a test had been completed.”

Source location
Response from Barts Health NHS
Page 2 · response
Published 23 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Brief staff to perform three safety checks of results at availability, referral or movement to SDEC, and discharge.

Verbatim wording from the response
“Learning from the incident has been shared widely within the department, including at induction and at daily safety briefings. Furthermore, all staff have been briefed on the need for 3 pauses for safety, whereby checks are undertaken when the result is first available, then rechecked at the point of referral/movement to SDEC (Same Day Emergency Care) unit and then a further check at the point of discharge.”

Source location
Response from Barts Health NHS
Page 2 · response
Published 23 September 2022
Open published response
17 Jun2022
Manchester West
Concerns raised4
1. Failure of collaborative working across organisations during hospital discharge
2. Failure to include relevant community care organisations in multidisciplinary discharge planning
3. Failure to ensure discharge accommodation is suitable for complex medical needs
1. Failure to notify relevant clinical professionals of patient discharges
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Victoria Cartwright · 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

Victoria Cartwright was pronounced dead on 26 December 2021 in a car park after consuming large amounts of alcohol and developing hypothermia while wearing unsuitable clothing for the weather. The principal concerns were that, despite recommendations for 24-hour care, she was discharged to accommodation considered unsuitable for her complex needs, and that there was insufficient collaborative working between the relevant hospital, mental health, social care and support organisations.

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 of collaborative working across organisations during hospital discharge
Wider context from the report
“████████ Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals. ████████ stated that this hotel would have been unsuitable for Victoria’s medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria’s actual discharges. ████████ a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria’s MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria’s complex needs and was not involved in the hospital discharge processes. Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve. ”
Source location
Victoria Cartwright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to include relevant community care organisations in multidisciplinary discharge planning
Wider context from the report
“████████ Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals. ████████ stated that this hotel would have been unsuitable for Victoria’s medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria’s actual discharges. ████████ a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria’s MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria’s complex needs and was not involved in the hospital discharge processes. Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve. ”
Source location
Victoria Cartwright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure discharge accommodation is suitable for complex medical needs
Wider context from the report
“████████ Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals. ████████ stated that this hotel would have been unsuitable for Victoria’s medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria’s actual discharges. ████████ a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria’s MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria’s complex needs and was not involved in the hospital discharge processes. Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve. ”
Source location
Victoria Cartwright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to notify relevant clinical professionals of patient discharges
Wider context from the report
“████████ Consultant Psychiatrist for Greater Manchester Mental Health Trust stated he had recommended a 24 hour care placement for Victoria to meet her clinical needs. Despite this, she was discharged from hospital to the Mercure Hotel, used to house homeless individuals. ████████ stated that this hotel would have been unsuitable for Victoria’s medical needs and following her readmission back to hospital, raised similar concerns. He also stated that he was never notified of Victoria’s actual discharges. ████████ a Recovery Co-Ordinator, employed by We Are With You (formerly Achieve) stated he was never invited to Victoria’s MDT meeting and it would have been beneficial for his organisation to have been taken part in this meeting. He concurred that the Mercure Hotel would have been unsuitable accommodation to suit Victoria’s complex needs and was not involved in the hospital discharge processes. Evidence highlights a lack of collaborative working between the discharge team, Wigan Hospital, GMMH and Achieve. ”
Source location
Victoria Cartwright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Jun2022
Nottinghamshire
Concerns raised1
1. Lack of clarity in multi-disciplinary team decision-making about discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Keith Andrew NOTTLE · Prevention of Future Deaths report

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

Report summary

Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity in multi-disciplinary team decision-making about discharge
Wider context from the report
“Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service. This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team. ”
Source location
Keith Andrew NOTTLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 May2022
North East Kent
Concerns raised1
1. Failure to define and identify carer breakdown before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Robert Arthur Brown · 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

Robert Arthur Brown, who had a history of suicide attempts and suicidal ideation, was discharged from hospital after four days without his wife being contacted. On 9 September 2020, he was found fatally injured at cliffs close to his home address. The principal concerns were that “carer breakdown” might not be identified before discharge and that, without a process requiring contact with a carer where no CPA was in place, anticipated care might not be available.

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 define and identify carer breakdown before discharge
Wider context from the report
“1. The Report states that “Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”. The evidence from the KMPT witness and subsequent documentation does not address what is meant and understood to be “carer breakdown” and as such may not be identified prior to discharge. ”
Source location
Robert Arthur Brown · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Apr2022
Manchester City
Concerns raised1
1. Failure to ensure safe discharge of patients requiring administered Depot antipsychotic medication
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Name not published · 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

The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure safe discharge of patients requiring administered Depot antipsychotic medication
Wider context from the report
“3. Discharging a patient with a long forensic history and inconsistent engagement with mental health services who still required administered Depot antipsychotic medication and was a vulnerable adult. ”
Source location
Name not published · Prevention of Future Deaths report
Page 3 · concerns
Open source report
7 Mar2022
Surrey
Concerns raised1
1. Insufficient discharge advice for potentially time-critical complaints
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

ARTHUR FREDERICK HALL · 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

Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

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
Insufficient discharge advice for potentially time-critical complaints
Wider context from the report
“5. Given the potential time-critical nature of Arthur’s possible complaint, more detailed discharge advice should have been given. ”
Source location
ARTHUR FREDERICK HALL · Prevention of Future Deaths report
Page 4 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to verify the most recent clinical observations and PEWS score before discharge

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

Concerns raised1

Lack of specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of specific guidance for expediting discharge of patients at high risk of acquiring Covid-19

Concerns raised1

Failure to await blood test results before discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to consider and act on dangerously elevated creatinine results before discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised4

Failure of collaborative working across organisations during hospital discharge

Failure to include relevant community care organisations in multidisciplinary discharge planning

Failure to ensure discharge accommodation is suitable for complex medical needs

Failure to notify relevant clinical professionals of patient discharges

Concerns raised1

Lack of clarity in multi-disciplinary team decision-making about discharge

Concerns raised1

Failure to define and identify carer breakdown before discharge

Actions described in response 3

Respondent positions 3

Actions described in response 4

Actions described in response 4