9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of coordinated discharge planning and joint working between trusts 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
Greater Manchester Mental Health NHS Foundation Trust Manchester University NHS Foundation Trust NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Manchester University NHS Foundation Trust
Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
View source
NHS Greater Manchester Integrated Care Board
Implement locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
View source
NHS Greater Manchester Integrated Care Board
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
View source
NHS Greater Manchester Integrated Care Board
Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
View source
NHS Greater Manchester Integrated Care Board
Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
View source
NHS Greater Manchester Integrated Care Board
Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
View source
NHS Greater Manchester Integrated Care Board
Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
View source
Greater Manchester Mental Health NHS Foundation Trust
Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
View source
Greater Manchester Mental Health NHS Foundation Trust
Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
View source See 6 more actions
×
AI-generated summary
Janet Alison Anderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
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 coordinated discharge planning and joint working between trusts
Wider context from the report “1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline.
She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge .
The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting
” Source location Janet Alison Anderson · Prevention of Future Deaths report
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 Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
Verbatim wording from the response “Actions taken by MFT
MFT accept that the established escalation processes through the PTL meeting did not achieve timely discharge for Mrs Anderson. This was largely a result of the specific circumstances of her case, particularly the requirement for her to be accommodated outside her current local authority area. However, as a result of her case, discussions have been held with colleagues in GMMH to provide a more robust escalation process where discharge being organised by the CMHT is taking longer than expected.” Source location Response from Manchester University NHS Foundation Trust
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 Implement locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
Verbatim wording from the response “To support the reduction, NHS GM localities have committed to and submitted Improvement Plans. These show that barriers to discharge remain, particularly in relation to accommodation pathways and individuals with complex needs. Localities are addressing these barriers through focused actions around step-up/step-down provision, targeted escalation approaches for complex patients, urgent and emergency care integration schemes, and coordinated planning for cross-border discharges. Manchester locality remains the locality with the highest number of Out of Area Placements (OAPs), Long Stay Patients (LSP’s), and CRFD cases. However, significant work has been undertaken and, as an example of progress to date, we have seen a 38% reduction in the Manchester locality, giving us confidence that our plans and actions are having an impact.” Source location Response from Greater Manchester Integrated Care
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 Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Verbatim wording from the response “GMMH have worked closely with NHS GM and Manchester commissioners to understand internal causes of delay, identify resource priorities, and explore immediate opportunities within existing services to reduce flow pressures. This work includes:” Source location Response from Greater Manchester Integrated Care
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 Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Verbatim wording from the response “• Improved CRFD escalation through a newly implemented senior system MADE forum” Source location Response from Greater Manchester Integrated Care
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 Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Verbatim wording from the response “In addition, a series of extraordinary MADE events have taken place, reviewing every CRFD case and identifying both individual and system-level blockers. One of the key actions agreed is the development of a consistent, end-to-end brokerage and funding pathway. This will define clear responsibilities, time standards at each stage, and introduce a formal protocol for cases that depend on external provider responses. In these cases, delays will be logged and monitored but not attributed to statutory agencies.” Source location Response from Greater Manchester Integrated Care
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 additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Verbatim wording from the response “• Additional Voluntary Community and Social Enterprise (VCSE) capacity in Manchester locality to support prevention of avoidable admissions and ensure timely discharge following inpatient admissions” Source location Response from Greater Manchester Integrated Care
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 Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Verbatim wording from the response “As well as the actions and improvements listed above, an escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3. This escalation process could be applied to the case of a patient who is CRFD in a medical bed but waiting for a package of care through a MH provider. The process, which is currently being piloted, provides a system aligned to 4 levels of escalation, levels 1-4. Any case where a mental health patient is CRFD with an unidentified barrier to discharge can be escalated.” Source location Response from Greater Manchester Integrated Care
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 Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
Verbatim wording from the response “Both Trusts have agreed to the opportunity to internally review Ms Anderson’s patient journey, GMMH will hold a Learning Multi-Disciplinary Team Meeting, with the following invitees:” Source location Response from Greater Manchester Mental Health
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 Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
Verbatim wording from the response “There are internal processes within GMMH which bring all patients who are identified as being ‘clinically ready for discharge’ (CRFD) into daily meetings to track progress in discharge planning and drive plans forward. From May 2024 Ms Anderson’s case and attempts to assess and identify a placement picked up in pace and focus as a result, but this should have been commenced earlier. There should be a focus on identifying barriers to discharge and making discharge planning the focus from the first day of admission; in many instances this is the case but clearly not in the instance of Ms Anderson where this only occurred once hitting CRFD. To rectify this, GMMH has developed a new post in the CMHT’s of a full time Operational Manager for Community Flow who will commence in post on 23 June 2025.” Source location Response from Greater Manchester Mental Health
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 concern about lack of joint working is disputed because the case was repeatedly discussed at daily meetings involving the relevant organisations.
Verbatim wording from the response “hospital but for whom there are other obstacles to discharge. This meeting is held daily and attended by representatives of the hospital, the Local Care Organisation (also part of MFT) and other relevant stakeholders including GMMH and the local authority.” Source location Response from Manchester University NHS Foundation Trust
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 Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Verbatim wording from the response “I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust (MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will respond to the issues specifically relating to Ms. Anderson’s care. I have responded to the issues you raise in light of the work undertaken by NHS GM as commissioner responsible for health and social care..” Source location Response from Greater Manchester Integrated Care
Open published response
23 Apr 2025 Lorraine Sandra Parker · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure to take postoperative CRP results into account in discharge and scanning decisions View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Lorraine Sandra Parker · 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
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
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 take postoperative CRP results into account in discharge and scanning decisions
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario . I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan .
” Source location Lorraine Sandra Parker · Prevention of Future Deaths report
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 Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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 Direct South East Clinical Quality colleagues to engage with the relevant ICB or Trust and seek assurance that learning from Lorraine’s case has been taken.
Verbatim wording from the response “NHS England notes the local delays in reporting experienced by Lorraine, who was sent home on 31 January 2024 without a post-operative scan despite an elevated CRP, together with the misreporting of the CT scan in February 2024. Clinical Quality colleagues in the South East region have been made aware of your Report and asked to engage with the relevant Integrated Care Board / Trust on the details of Lorraine’s case and to seek assurance that learnings have been taken.” Source location Response from NHS England
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 Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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 ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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 Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Verbatim wording from the response “With regard to concerns about guidance for clinicians, the NICE guideline on colorectal cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer by providing evidence-based recommendations on the management of both local disease and metastatic (secondary) cancer. It covers which interventions should be used for different types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and other treatments.” Source location Response from DHSC
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 NHS Trusts are responsible for ensuring staff competence and should review their clinical protocols following the case.
Verbatim wording from the response “With regard to concerns about clinical judgement, NHS Trusts are responsible for ensuring staff are sufficiently competent to deliver care. Accordingly, the Trust in question should consider their protocols in the wake of this case. The CQC has passed details of the case to the relevant inspection team for Royal Berkshire Hospital for further consideration.” Source location Response from DHSC
Open published response
9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of suitable non-acute or community provision for medically optimised patients View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Bernard Lyon · 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
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.
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 suitable non-acute or community provision for medically optimised patients
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available .
” Source location Bernard Lyon · Prevention of Future Deaths report
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 Publish the revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.
Verbatim wording from the response “More broadly, this government is committed to tackling delayed discharges through the Better Care Fund (BCF), and its revised policy framework, published on 31 January 2025. For 2025-26, approximately £9 billion is committed to the BCF. This includes around £3.3 billion provided to local authorities and £5.6 billion to integrated care boards, both of which” Source location Response from Department of Health and Social Care
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 Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect” Source location Response from CQC
Open published response
28 Mar 2025 Derrick Frederick Tully · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to account for cognitive, mental health and home-safety barriers when assessing engagement View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
London Borough of Islington Whittington Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Whittington Health NHS Trust
Conduct an independent structured judgement review and discuss its findings at ICAT governance and safeguarding meetings.
View source
Whittington Health NHS Trust
Add assessment-proforma requirements to consult patients’ families where appropriate and document mental-capacity decisions when patients do not consent.
View source
Whittington Health NHS Trust
Conduct mental-capacity assessments for patients who do not engage with services and involve families where appropriate.
View source
London Borough of Islington
Revisit training on identifying cognitive abilities, capacity, risk, and risk management under the Mental Capacity Act.
View source See 1 more action
×
AI-generated summary
Derrick Frederick Tully · 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
Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.
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 account for cognitive, mental health and home-safety barriers when assessing engagement
Wider context from the report “Following MDT meetings due to concerns over Derrick’s increasing deterioration and ability to cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. They discharged him from the service on 12 March because he did not want to engage with their home assessment of him . Derrick was suffering from cognitive impairment as a result of previous strokes and newly diagnosed dementia. He also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team .
” Source location Derrick Frederick Tully · Prevention of Future Deaths report
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 Conduct an independent structured judgement review and discuss its findings at ICAT governance and safeguarding meetings.
Verbatim wording from the response “The Lead Consultant for the Integrated Community Aging team (ICAT) has confirmed that families are usually involved as much as possible in assessments with the consent of patients in ICAT service. Where a patient does not have capacity to decline speaking with their next of kin, attempts are made to do so in their best interests. It is unclear why this did not happen in this case, and this will be explored in detail following an independent structured judgement review at the next ICAT governance meeting on May 21st, 2025. The minutes for those unable to attend will be disseminated by email and one to one discussions. This case will also be discussed at weekly Safeguarding drop ins on 6th May 2025.” Source location Response from Whittington Health NHS Trust
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 Add assessment-proforma requirements to consult patients’ families where appropriate and document mental-capacity decisions when patients do not consent.
Verbatim wording from the response “In terms of how such incidents will be addressed in future, the learning from this case will be taken to the governance, Clinical and Quality Lead and team meetings. In addition, details will be added to the assessment proforma around engagement with the next of kin to get collateral history and discuss concerns, if the patient consents to this. If the patient does not give consent, a mental capacity assessment will be conducted and documented around this decision and discussed at MDT with the lead clinician.” Source location Response from Whittington Health NHS Trust
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 Conduct mental-capacity assessments for patients who do not engage with services and involve families where appropriate.
Verbatim wording from the response “• Mental capacity assessment will be conducted for all patients when they are not engaging with services as well as family involvement where appropriate.” Source location Response from Whittington Health NHS Trust
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 Revisit training on identifying cognitive abilities, capacity, risk, and risk management under the Mental Capacity Act.
Verbatim wording from the response “In response to the coroner’s findings, Islington does support its workforce through training, audit and the support of the principal social worker with the skills to identify issues relating to residents’ cognitive abilities, their capability to identify risk and the management of that risk in line with the Mental Capacity Act 2005 and its principles. Islington Council will revisit this training in the light of the coroner’s findings.” Source location Response from Islington Council
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 team had received and considered information about the patient’s unsafe home circumstances, neighbours and self-care difficulties.
Verbatim wording from the response “DT also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team.” Source location Response from Whittington Health NHS Trust
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 ICAT discharged the patient because other community services addressed all identified problems and provided a safety net for ongoing follow-up.
Verbatim wording from the response “In terms of the decision making around discharge, although Derrick’s refusal for ongoing assessment was a factor, the primary reason for discharge was that all the identified problems were being addressed by existing teams and ICAT could not add anything further to Derrick’s care. In addition, as he remained under Integrated Networks Coordinators (INC) and several other community services there was a safety net in place in terms of ongoing follow up.” Source location Response from Whittington Health NHS Trust
Open published response
19 Mar 2025 Winnie Harrop · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs View source Failure of discharge letters to communicate clinically significant sedation and oxygen requirements View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Winnie Harrop · 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
Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.
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 that discharge to a non-nursing care home is appropriate for a patient's condition and care needs
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated . The care home was not a nursing home . Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement.
” Source location Winnie Harrop · 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 discharge letters to communicate clinically significant sedation and oxygen requirements
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement .
” Source location Winnie Harrop · Prevention of Future Deaths report
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 Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.
Verbatim wording from the response “Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.” Source location Response from NHSE
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 Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.
Verbatim wording from the response “Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.” Source location Response from NHSE
Open published response
17 Mar 2025 DARREN NEIL TURNER · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Chaotic and unsupported discharge execution View source Failure to actively reconsider discharge safety when arrangements change View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University 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
Essex Partnership University NHS Foundation Trust
Recruit a Community and Inpatient Liaison Nurse to coordinate inpatient referrals and support safe discharge.
View source
Essex Partnership University NHS Foundation Trust
Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.
View source
Essex Partnership University NHS Foundation Trust
Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
View source
Essex Partnership University NHS Foundation Trust
Complete a thematic review of inpatient deaths to inform discharge safety improvements.
View source
Essex Partnership University NHS Foundation Trust
Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
View source
Essex Partnership University NHS Foundation Trust
Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
View source See 3 more actions
×
AI-generated summary
DARREN NEIL TURNER · 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
Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.
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 Chaotic and unsupported discharge execution
Wider context from the report “(f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from Darren’s mother that she would not, as had been previously indicated, be able to either collect Darren from the Ward or be at her home when he was discharged. There was no evidence of how, in fact, Darren even left the Unit. It is likely that the chaotic and unsupported nature of Darren’s discharge from Gosfield Ward, also in breach of Trust policy , more than minimally contributed to his death some 18 hours after discharge.
” Source location DARREN NEIL TURNER · 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 actively reconsider discharge safety when arrangements change
Wider context from the report “(f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from Darren’s mother that she would not, as had been previously indicated, be able to either collect Darren from the Ward or be at her home when he was discharged . There was no evidence of how, in fact, Darren even left the Unit. It is likely that the chaotic and unsupported nature of Darren’s discharge from Gosfield Ward, also in breach of Trust policy, more than minimally contributed to his death some 18 hours after discharge.
” Source location DARREN NEIL TURNER · Prevention of Future Deaths report
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 Recruit a Community and Inpatient Liaison Nurse to coordinate inpatient referrals and support safe discharge.
Verbatim wording from the response “The Gables SMHT are currently in the process of recruiting a Community and Inpatient Liaison Nurse lead band 6 Community Psychiatric Nurse (CPN). The post holder is to work directly with inpatient services. All inpatients who are referred to the Gables SMHT will be allocated to this CPN. It is envisaged that the staff member will meet with the patients on the ward, attend ward review and work closely with the inpatient team to ensure a safe discharge, improve communication and provide a more seamless service.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.
Verbatim wording from the response “Going forward the appropriate Home Treatment Team will be invited to attend ward review meeting on day of discharge to ensure they have the most up to date information in relation to planned discharges.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
Verbatim wording from the response “Additionally, on discharge, an allocated registered nurse on shift will take responsibility for working with the patient to prepare for safe discharge including home travel plans, ensuring support network plan is in place, contact / follow up advice and crisis contingency plan.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Complete a thematic review of inpatient deaths to inform discharge safety improvements.
Verbatim wording from the response “The Trust has initiated a Discharge SIP (Safety Improvement Plan). The Urgent Care and Inpatient Care Unit leadership team through the PSIRF process carried out a table top exercise in April 2024 to review inpatient safety incidents where unexpected death had occurred over the last 10 years (2014 – 2024) from an operational, and quality and safety lens.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
Verbatim wording from the response “This 10 year thematic review of in-patient deaths informed the Discharge SIP and contributed to the development of a new in patient operating model in 2024. This along with newly published NHSE guidance for in-patient wards for working age and older people has provided an opportunity for a full review of the culture, systems and process to maximise the patient and staff experience, improve quality and safety and align with community mental health and system partners. The model incorporates four chapters – ‘Purposeful Admission’, ‘Therapeutic Benefit’, ‘Trauma Informed Care’ and ‘Proactive, Safe and Effective Discharge’ which is supported by a detailed implementation plan, which is currently being mobilised across all adult and older adult wards. Community services and Family & Carer engagement is key within the Proactive, Safe and Effective Discharge chapter.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
Verbatim wording from the response “The Trust has established family ambassadors on the wards who are a key point of contact for families and are responsible for ensuring information shared by families is recorded and considered by the MDT.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Concerns raised 1
Failure to involve community care co-ordinators and professionals in multidisciplinary discharge decisions 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
Swansea Bay University Local Health Board
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
Swansea Bay University Local Health Board
Hold weekly multidisciplinary ward meetings with community mental health services and other agencies to support collaborative discharge decisions.
View source
Swansea Bay University Local Health Board
Hold weekly discharge planning meetings attended by inpatient and community team representatives to discuss and prioritise discharge plans.
View source
Swansea Bay University Local Health Board
Use a revised pre-discharge checklist requiring communication and collaboration with care coordinators, families, carers and relevant agencies, with weekly clinical-record audits.
View source
Swansea Bay University Local Health Board
Undertake a clinical audit of adult inpatient discharges against national transition guidance and present its findings.
View source
Swansea Bay University Local Health Board
Issue formal correspondence reaffirming compliance with discharge-planning policy, the pre-discharge checklist and patient information requirements.
View source
Swansea Bay University Local Health Board
Cascade the discharge-planning correspondence through ward, team-manager and consultant forums.
View source See 3 more actions
×
AI-generated summary
Jean Pike · 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
Jean Pike, who had suicidal thoughts and intended to hang herself, was left unattended for between 20 and 45 minutes in her supported living accommodation and was then found suspended and declared deceased on 18 May 2022. The concerns included hospital discharge decisions made without multidisciplinary consultation with community professionals, inadequate consideration of risks, and an inadequate safety plan before Jean was left unattended.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to involve community care co-ordinators and professionals in multidisciplinary discharge decisions
Wider context from the report “I am concerned that Jean was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean’s mental health and the risks she posed to herself in the community . This was in circumstances where the consultant knew before the decisions to discharge that these professionals, which included Jean’s care co-ordinator, were clearly stating that they were extremely concerned about Jean’s mental health and that they did not consider that they could keep Jean safe in the community and that they thought that Jean would hang herself in the community – which is in fact what happened in this case. I am particularly concerned by the evidence I heard from Jean’s care co-ordinator that care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care . This issue was not identified by Swansea Bay University Health Board (“SUBHB”) in their internal investigation into Jean’s death. This investigation found that “there is evidence of regular and effective communication between support staff, community staff and hospital staff”.
The above finding of SUBHB’s internal investigation raises a concern that critical lessons have not being identified and learnt by SUBHB from Jean’s death about the importance of multi-disciplinary decision making in clinical care and risk management and the importance of including care co-ordinators and professionals in the community before a decision is taken to discharge a patient from Ward F . This creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F. I am also concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care co-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patient/person under secondary care will not be adequately considered in the decisions made by Ward F clinicians . This also creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F.
” Source location Jean Pike · Prevention of Future Deaths report
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 Hold weekly multidisciplinary ward meetings with community mental health services and other agencies to support collaborative discharge decisions.
Verbatim wording from the response “Discharge processes within the adult mental health wards have been reviewed over the last three years and Terms of Reference were developed for the Multi-Disciplinary Team (MDT) Ward meetings in April 2022. The MDT meeting is held on a weekly basis, with the focus being to work collaboratively with colleagues in the Community Mental Health Services and other agencies/providers to provide holistic and patient centred care. The Terms of Reference for the MDT meetings and review process sets out the purpose and expectation of all parties within this process; including collaboration with care coordinators, families, and other agencies. Prior to each MDT meeting, a communication is sent to all Integrated team managers for CMHTs (this includes the Local Authority and Health manager), informing them of the MDT meeting agenda.” Source location Response from Swansea Bay University Health Board
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 Hold weekly discharge planning meetings attended by inpatient and community team representatives to discuss and prioritise discharge plans.
Verbatim wording from the response “Within the adult Mental Health services, a weekly discharge planning meeting is held, where all inpatients progress and discharge plans are discussed and prioritised. Attendees at this meeting are representatives from each of the inpatient and community teams. The purpose of this meeting is for information sharing, working collaboratively to inform effective patient flow and discharge planning through the service.” Source location Response from Swansea Bay University Health Board
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 a revised pre-discharge checklist requiring communication and collaboration with care coordinators, families, carers and relevant agencies, with weekly clinical-record audits.
Verbatim wording from the response “There are going to be times where patients are appropriate for discharge in circumstances outside of the above meetings; such as a short admission, in this situation and for planned discharged, the utilisation of a discharge checklist ensures that there is effective communication and collaboration with all parties. The purpose of the Pre-discharge checklist is to provide an overview of the necessary actions required in preparation for a patient discharge. The checklist includes the required stakeholders who need to attend, such as family/carer or advocacy, care coordinator, care providers and any other agencies involved. Other aspects of the checklist include social circumstances, occupational therapy needs, safeguarding, follow up from the Crisis resolution and home treatment team, and take-home medication requirements.” Source location Response from Swansea Bay University Health Board
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 Undertake a clinical audit of adult inpatient discharges against national transition guidance and present its findings.
Verbatim wording from the response “Discharge planning has been a focus of a current clinical audit that is being undertaken by the Quality Improvement and Practice Development teams. This audit is looking at Discharges from the Adult Inpatient Wards against the guidance identified in NG53 Transition between inpatient Mental Health Settings and Community or Care home settings. This audit commenced in March 2025 and the findings are planned to be presented in July 2025.” Source location Response from Swansea Bay University Health Board
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 Issue formal correspondence reaffirming compliance with discharge-planning policy, the pre-discharge checklist and patient information requirements.
Verbatim wording from the response “In addition to these, the Medical Director and Nurse Director for MH&LD have issued formal correspondence to all clinical areas and teams, reaffirming adherence to Section 3.4: Discharge and Discharge Planning of the Acute Adult Mental Health Inpatient Wards Operational Policy and the Pre-Discharge Planning Checklist and the patient/relative receives the “Moving on” information leaflet.” Source location Response from Swansea Bay University Health Board
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 Cascade the discharge-planning correspondence through ward, team-manager and consultant forums.
Verbatim wording from the response “This formal correspondence will also be cascaded through the relevant forums throughout May 2025, such as Ward/Team manager meetings and consultant forums.” Source location Response from Swansea Bay University Health Board
Open published response
6 Mar 2025 Annette Lewis · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to implement a “Failed Discharge” policy View source
×
AI-generated summary
Annette Lewis · 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
Annette Lewis re-presented to hospital with worsening abdominal pain and was discharged without full consideration of her symptoms and test results. She was declared deceased at home on 18 April 2023; the medical cause of death was recorded as peritonitis and upper gastrointestinal haemorrhage due to a perforated pyloric ulcer. The principal concern was that she should have been referred for surgical review rather than discharged, and that a proposed “Failed Discharge” policy had no definitive implementation timescale.
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 implement a “Failed Discharge” policy
Wider context from the report “Annette should have been referred for surgical review rather than being discharged.
Work on a “Failed Discharge” policy has been ongoing for some time. When implemented, patients re-attending Emergency Departments in similar circumstances would be automatically and swiftly filtered to the appropriate specialist team , which would reduce the risks for those individual patients and reduce the pressures and the consequent risk of errors within Emergency Departments. Progress with this policy has been difficult and there is no definitive timescale for implementation.
” Source location Annette Lewis · Prevention of Future Deaths report
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 operational general surgery guidelines for patients returning to emergency departments after discharge, and embed them in governance, staff induction and accessible policy resources.
Verbatim wording from the response “1. General Surgery Policy
CTM now has active and up to date guidelines to prevent recurrence of what happened in Mrs Lewis’ case. This is a General Surgery policy that applies to the General Surgeons as well as to the Emergency Department (who have also had it discussed and shared” Source location Response from Cwm Taf Morgannwg University Health Board
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 Existing guidelines, policies and awareness measures are considered sufficient to prevent further similar patient presentations.
Verbatim wording from the response “widely – please see below in Emergency Department section). The Guidelines for care and treatment for patients who return to an Emergency Department (ED) within CTM UHB with general surgical conditions following discharge from hospital within CTM UHB were approved at Quality & Safety Committee on the 25th March 2025. These guidelines are operational across the Health Board. It was discussed at the Surgical Governance Meeting (pan-health board) on 13th March 2025 department Morbidity and Mortality meeting, and the new policy was shared with the entire team by email. Those involved have reflected and evidenced this as part of their appraisal. Finally, this policy has been included in our induction presentation to all new starters. It is available on the Health Board SharePoint where all Guidelines and Policies are located for rapid access by colleagues.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
31 Jan 2025 Alexander Channing · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1
Lack of responsible clinician involvement in discharge planning View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Devon Partnership NHS Trust Dorset Healthcare University 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
Devon Partnership NHS Trust
Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.
View source
Dorset Healthcare University NHS Foundation Trust
Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
View source
Dorset Healthcare University NHS Foundation Trust
Provide discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.
View source
Dorset Healthcare University NHS Foundation Trust
Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
View source
Dorset Healthcare University NHS Foundation Trust
Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
View source See 2 more actions
×
AI-generated summary
Alexander Channing · 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
Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.
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 responsible clinician involvement in discharge planning
Wider context from the report “iii. There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust.
” Source location Alexander Channing · Prevention of Future Deaths report
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 Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.
Verbatim wording from the response “In terms of discharge planning from Liaison Psychiatry, in relation to the planned discharge from the district hospital in Exeter, I can confirm that the following paragraph has been added to the Liaison Psychiatry Services Exeter, Torquay and Barnstaple Specialist Services Directorate Standard Operating Procedure. It gives detail on page 12 of the attached document.” Source location Response from Devon Partnership NHS Trust
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 Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
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 discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.
Verbatim wording from the response “Following the conclusion of the inquest, feedback was provided at a local level at multi-disciplinary team meetings in the relevant area, this feedback included the concerns expressed by the Coroner and the experience of Alec's family.” Source location Response from Dorset Healthcare NHS
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 Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
Verbatim wording from the response “Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.” Source location Response from Dorset Healthcare NHS
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 Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
Verbatim wording from the response “Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.” Source location Response from Dorset Healthcare NHS
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 Dorset HealthCare disputes involvement in the discharge planning concerned, stating it was only contacted to arrange a psychiatric outpatient appointment.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
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 Discharge arrangements are led by the team seeking to transfer care, assigning responsibility to the transferring NHS provider.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
Open published response
31 Jan 2025 Nicola Emma OWENS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Backlog of patients fit for discharge awaiting social care packages View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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
Department of Health and Social Care
Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
View source
Department of Health and Social Care
Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
View source
NHS England
Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
View source
NHS England
Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
View source
NHS England
Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
View source
NHS England
Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
View source See 3 more actions
×
AI-generated summary
Nicola Emma OWENS · 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
Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.
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 Backlog of patients fit for discharge awaiting social care packages
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages . Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Source location Nicola Emma OWENS · Prevention of Future Deaths report
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 Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
Verbatim wording from the response “Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.” Source location Response from DHSC
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 Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
Verbatim wording from the response “We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.” Source location Response from DHSC
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 Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
Verbatim wording from the response “NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.” Source location Response from NHS England
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 Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
Verbatim wording from the response “NHS England recognises that delayed discharges have a significant impact on hospital flow, capacity and ambulance handovers. In order to address this, NHS England is strengthening the use of Discharge Ready Date (DRD) data in order to gain a clearer understanding of discharge delays and their key contributing factors.” Source location Response from NHS England
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 Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
Verbatim wording from the response “NHS England has also published the 2025/26 Better Care Fund (BCF) policy framework and planning requirements, working alongside the Department of Health and Social Care (DHSC) and Ministry of Housing, Communities and Local Government. The BCF framework supports local systems to jointly agree plans across health and care, including supporting the flow of patients through UEC.” Source location Response from NHS England
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 Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
Verbatim wording from the response “NHS England will be working with local areas to support them to maximise the impact of this investment over the coming year, by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including Local Government Associations, Directors of Social Services, and Care and Health Improvement advisors to support local systems to improve timely discharge of patients.” Source location Response from NHS England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.