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 Mar2023
East London
Concerns raised1
1. Failure to complete a comprehensive risk assessment 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.

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

Carol Ann Robinson · 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

Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.

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 complete a comprehensive risk assessment before discharge
Wider context from the report
“2. Mrs Robinson did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022. ”
Source location
Carol Ann Robinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Mar2023
Inner West London
Concerns raised3
1. Failure to contact emergency contacts or next of kin before or at discharge
2. Failure to arrange follow-up appointments before discharge
3. Failure to contact the patient after discharge
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Remind hospital colleagues to notify next of kin or emergency contacts after self-discharge against medical advice when the patient consents.
  Stated by Priory GroupStated completed
2. Action
  Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
  Stated by Priory GroupStated completed
3. Action
  Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
  Stated by Priory GroupStated planned
1. Action
  Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
  Stated by Priory GroupStated in progress
2. Action
  Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.
  Stated by Priory GroupStated completed
3. Action
  Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.
  Stated by Priory GroupStated in progress
Respondent positions 1
1. Position
  The hospital considers discharge arrangements appropriate because the patient was low risk, had capacity, and withdrew consent to sharing information with family.
  Stated by Priory GroupDisputes the concern
AI-generated summary

Annabel Jean Findlay · 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

Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause of death.

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 contact emergency contacts or next of kin before or at discharge
Wider context from the report
“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
Source location
Annabel Jean Findlay · 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 arrange follow-up appointments before discharge
Wider context from the report
“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
Source location
Annabel Jean Findlay · 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 contact the patient after discharge
Wider context from the report
“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
Source location
Annabel Jean Findlay · 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
Remind hospital colleagues to notify next of kin or emergency contacts after self-discharge against medical advice when the patient consents.

Verbatim wording from the response
“However, in the interest of learning, the PHR Hospital Director, ████████, has shared a reminder with hospital colleagues of the requirement to notify the next of kin or emergency contact of a patient, when self-discharge is taken against medical advice, where a patient consents to this information being shared. This was discussed during a Consultants’ meeting held on Thursday 6 April 2023 and during a Clinical Governance meeting held on Thursday 20 April 2023.”

Source location
Response from Priory
Page 1 · response
Published 10 March 2023
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
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
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 a further reminder requiring outpatient follow-up appointments to be booked before discharge.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
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
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.

Verbatim wording from the response
“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
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
Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.

Verbatim wording from the response
“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
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
Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.

Verbatim wording from the response
“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location
Response from Priory
Page 2 · response
Published 10 March 2023
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 hospital considers discharge arrangements appropriate because the patient was low risk, had capacity, and withdrew consent to sharing information with family.

Verbatim wording from the response
“You have raised a concern that staff did not contact Ms Findlay’s next of kin / emergency contact at the point of her discharge from hospital.”

Source location
Response from Priory
Page 1 · response
Published 10 March 2023
Open published response
19 Feb2023
Essex
Concerns raised3
1. Lack of escalation when assessment and discharge planning requests are not answered
2. Lack of assessment of section 117 needs for discharge
3. Insufficient assessment of the impact of autism diagnosis in discharge planning
This report raised 10 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 5
1. Action
  Operate a monthly Mental Health Resolution Forum to resolve liaison issues between Children and Families, EWMHS and Tier 4 specialist commissioning.
  Stated by Essex County CouncilStated completed
2. Action
  Require Child and Family Assessments and continued Social Care involvement for every young person admitted to a Tier 4 inpatient bed.
  Stated by Essex County CouncilStated completed
3. Action
  Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.
  Stated by Essex County CouncilStated completed
1. Action
  Develop and publish internal Section 117 guidance covering duties, processes and the Section 117 Panel.
  Stated by Essex County CouncilStated planned
2. Action
  Complete the draft Section 117 practice guidance and produce a Thinking Practice Tool to support Section 117 planning.
  Stated by Essex County CouncilStated planned
Respondent positions 1
1. Position
  The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
  Stated by Essex County CouncilDisputes the concern
AI-generated summary

Molly Ann Sergeant · 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

Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.

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 escalation when assessment and discharge planning requests are not answered
Wider context from the report
“(4) Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence. ”
Source location
Molly Ann Sergeant · 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
Lack of assessment of section 117 needs for discharge
Wider context from the report
“(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council: a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless. b. Lack of assessment for any s117 needs to facilitate discharge c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made. ”
Source location
Molly Ann Sergeant · Prevention of Future Deaths report
Page 3 · 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
Insufficient assessment of the impact of autism diagnosis in discharge planning
Wider context from the report
“(2) There was insufficient assessment for discharge planning purposes of the impact of Molly’s recent diagnosis of Autism by Essex Partnership NHS Foundation Trust ”
Source location
Molly Ann Sergeant · 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
Operate a monthly Mental Health Resolution Forum to resolve liaison issues between Children and Families, EWMHS and Tier 4 specialist commissioning.

Verbatim wording from the response
“There is a Mental Health Resolution Forum which meets monthly – this focuses on liaison and resolution issues between Children and Families, EWMHS and Tier 4 Specialist Commissioning. Core agencies are represented at Director / Head of Service level. This was established in 2018”

Source location
Response from Essex County Council
Page 3 · response
Published 10 March 2023
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
Require Child and Family Assessments and continued Social Care involvement for every young person admitted to a Tier 4 inpatient bed.

Verbatim wording from the response
“There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.”

Source location
Response from Essex County Council
Page 3 · response
Published 10 March 2023
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
Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.

Verbatim wording from the response
“There is a pan-Essex SET Section 117 Protocol which was published in April 2022. This highlights the primary purposes of Section 117 and is intended to articulate a clear process by which multi-agency care planning in the context of Section 117 should be undertaken. It makes clear reference to the provision of accommodation issues within the Section 117 arrangements. It is currently a 26-page document.”

Source location
Response from Essex County Council
Page 4 · response
Published 10 March 2023
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 and publish internal Section 117 guidance covering duties, processes and the Section 117 Panel.

Verbatim wording from the response
“There is also an internal Section 117 guidance working group which has been developed by the Leads for Mental Health within ECC. This is due to be published in Spring 2023. This will cover Section 117 duties and responsibilities, the Section 117 process, the Section 117 Panel.”

Source location
Response from Essex County Council
Page 4 · response
Published 10 March 2023
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 the draft Section 117 practice guidance and produce a Thinking Practice Tool to support Section 117 planning.

Verbatim wording from the response
“The draft Section 117 practice guidance will be completed in the Spring 2023, and a “Thinking Practice Tool “will be produced to assist staff in relation to the issues involved in Section 117 planning.”

Source location
Response from Essex County Council
Page 4 · response
Published 10 March 2023
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 acknowledged shortcomings were not causation or contributory factors in Molly’s death.

Verbatim wording from the response
“It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.”

Source location
Response from Essex County Council
Page 2 · response
Published 10 March 2023
Open published response
7 Feb2023
Manchester North
Concerns raised1
1. Failure of Recovery and Discharge Plans to address online medication procurement risks
This report raised 9 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

Ania Sohail · 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

Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

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 Recovery and Discharge Plans to address online medication procurement risks
Wider context from the report
“(2) The Recovery & Discharge Plans did not address the risks associated with Ania’s procurement of Propranolol from on-line pharmacies. The evidence was that an update of the Recovery & Discharge Plan involved members of nursing staff simply adding a note that the overdoses had taken place. The Plan did not show that any meaningful thought had been given to addressing the particular risk associated with the procurement of on-line medication. ”
Source location
Ania Sohail · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Feb2023
Sunderland
Concerns raised1
1. Lack of comprehensive planning for home leave and discharge from hospital
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 2
1. Action
  Include contingency planning to reduce repeat self-harm risk in updated Trust training materials.
  Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completed
2. Action
  Improve communication with carers and family members through disseminating lessons learned, training and continuous audit.
  Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  The Trust considers multidisciplinary assessment, gradual leave progression, recall powers and monitoring sufficient for leave and discharge planning.
  Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  The Trust considers the risk assessment, safety plan and contingency planning appropriate to known circumstances and sufficient to mitigate risks.
  Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Daniel Graeme Futers · 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 Graeme Futers died after falling from Wearmouth Bridge, Sunderland, on 5 April 2022. The report identified concerns about incomplete recording of information, inadequate planning for home leave and discharge, and insufficient situational awareness, including reconciliation of conflicting accounts about him.

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 comprehensive planning for home leave and discharge from hospital
Wider context from the report
“2. Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family. ”
Source location
Daniel Graeme Futers · 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
Include contingency planning to reduce repeat self-harm risk in updated Trust training materials.

Verbatim wording from the response
“c. The risk assessment and associated plan is appropriate, the clinician and patient have a full and open discussion about risk and then between the point of the assessment and the incident, something changes to escalate risk that the clinician could not be aware of or have foreseen. Again, there are limits to the extent to which this can be mitigated against, however contingency planning to reduce the risk of a repeat self-harm attempt is specifically covered in the updated Trust training materials. Contingency and safety planning was evident in this case.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 13 February 2023
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
Improve communication with carers and family members through disseminating lessons learned, training and continuous audit.

Verbatim wording from the response
“In respect of communication with carers/family members, this is a matter which the Trust takes very seriously and acknowledges is an important part of patient care and treatment. The Trust is continuously driving improvement in this area by way of the dissemination of lessons learned, training and continuous audit.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 6 · response
Published 13 February 2023
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 considers multidisciplinary assessment, gradual leave progression, recall powers and monitoring sufficient for leave and discharge planning.

Verbatim wording from the response
“In light of the above, the Trust considers that there had been comprehensive multi-disciplinary consideration of Daniel’s case prior to his s.17 leave being granted which was in line with the Trust policy/procedure in respect of s.17 leave. ████████ explained in his evidence that once Daniel had started to respond to treatment, his leave had been progressed gradually as part of his care and treatment plan alongside his depot medication. ████████ confirmed that there was no reason to suggest that the plan in place was not appropriate and that both Daniel’s subjective and objective presentation were considered in reaching this decision. To the extent that there had been any discrepancy between the objective and subjective presentation, ████████ confirmed that the decision to grant leave would have been reconsidered accordingly.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 4 · response
Published 13 February 2023
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 considers the risk assessment, safety plan and contingency planning appropriate to known circumstances and sufficient to mitigate risks.

Verbatim wording from the response
“b. The risk assessment and associated plan is appropriate to the known circumstances however an individual has not disclosed their true thoughts and intentions in the course of the assessment. The Trust trains its clinicians to mitigate against this risk in so far as possible but there are limitations to what can practically be achieved and the subjective element of risk assessment cannot be eliminated completely. The risk assessments in this case take into account subjective and objective presentation, and collateral information from the family during the leave period. As set out above no issues were identified in the in depth review of the case that suggested a lack of clinical curiosity when considering Daniel’s presentation and treatment plan.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 13 February 2023
Open published response
27 Jan2023
East London
Concerns raised1
1. Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
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

Toby Wilbur Barwick · 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

Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.

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 provide maternity discharge advice and documentation on SIDS and recommended safe practices
Wider context from the report
“1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome (“SIDS”). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied. ”
Source location
Toby Wilbur Barwick · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jan2023
Norfolk
Concerns raised1
1. Failure to discharge medically fit patients when suitable community beds are unavailable
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.
Actions described in response 2
1. Action
  Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Ensure every acute hospital has access to a care transfer hub for complex discharges.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Lyn Mary BRIND · 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

Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.

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 discharge medically fit patients when suitable community beds are unavailable
Wider context from the report
“6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. 7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. 8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. 7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community ”
Source location
Lyn Mary BRIND · 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
Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.

Verbatim wording from the response
“We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 January 2023
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
Ensure every acute hospital has access to a care transfer hub for complex discharges.

Verbatim wording from the response
“We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 January 2023
Open published response
5 Dec2022
Inner North London
Concerns raised3
1. Failure to involve district nursing team in discharge planning
2. Failure to arrange pressure-relieving bed and mattress replacement before discharge
3. Omission of daily skin-integrity checking instruction from discharge assessment form
This report raised 6 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 27
1. Action
  Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
2. Action
  Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
  Stated by Central London Community Healthcare NHS TrustStated completed
3. Action
  Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
1. Action
  Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
2. Action
  Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
  Stated by Kapital Care (UK) LimitedStated planned
3. Action
  Ensure robust and timely communication with all agencies involved in care arrangements.
  Stated by Kapital Care (UK) LimitedStated in progress
4. Action
  Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
  Stated by Westminster City CouncilStated completed
5. Action
  Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
6. Action
  Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
7. Action
  Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
8. Action
  Contact district nurses whenever they are involved in an adult’s care arrangements.
  Stated by Kapital Care (UK) LimitedStated planned
9. Action
  Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
  Stated by Central London Community Healthcare NHS TrustStated completed
10. Action
  Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
  Stated by Central London Community Healthcare NHS TrustStated completed
11. Action
  Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
12. Action
  Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
  Stated by Kapital Care (UK) LimitedStated planned
13. Action
  Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
  Stated by Kapital Care (UK) LimitedStated planned
14. Action
  Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
  Stated by University College London Hospitals NHS Foundation TrustStated completed
15. Action
  Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
  Stated by Kapital Care (UK) LimitedStated planned
16. Action
  Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
  Stated by Kapital Care (UK) LimitedStated planned
17. Action
  Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
  Stated by Central London Community Healthcare NHS TrustStated completed
18. Action
  Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
  Stated by University College London Hospitals NHS Foundation TrustStated in progress
19. Action
  Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
20. Action
  Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
  Stated by Kapital Care (UK) LimitedStated completed
21. Action
  Review organisational recording and documentation practices.
  Stated by Kapital Care (UK) LimitedStatus unclear
22. Action
  Obtain the relevant discharge notification form before starting hospital-discharge care packages.
  Stated by Kapital Care (UK) LimitedStated planned
23. Action
  Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
  Stated by Westminster City CouncilStated in progress
24. Action
  Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
  Stated by University College London Hospitals NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
  Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Richard Thomas SHANNON · Prevention of Future Deaths report

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

Report summary

Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.

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 district nursing team in discharge planning
Wider context from the report
“1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 3 · 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 arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report
“1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 3 · 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
Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report
“4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. ”
Source location
Richard Thomas SHANNON · Prevention of Future Deaths report
Page 4 · 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
Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.

Verbatim wording from the response
“• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 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
Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.

Verbatim wording from the response
“• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.”

Source location
Response from Central London Community Healthcare
Page 1 · response
Published 8 December 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 the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.

Verbatim wording from the response
“• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 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
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 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
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.

Verbatim wording from the response
“• Kapital Care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.”

Source location
Response from Kapital Care
Page 1 · response
Published 8 December 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
Ensure robust and timely communication with all agencies involved in care arrangements.

Verbatim wording from the response
“• Kapital care is ensuring robust and timely communication is undertaken with all agencies.”

Source location
Response from Kapital Care
Page 3 · response
Published 8 December 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 a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.

Verbatim wording from the response
“• To support an all-agency approach to discharge planning, social workers now use a checklist to ensure that all aspects of the care plan have been actioned prior to discharge, e.g., equipment delivery, district nurse involvement, care agency fully briefed. This is to minimise the risk of there being any gaps in the discharge process across all agencies.”

Source location
Response from City of Westminster
Page 2 · response
Published 8 December 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
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.

Verbatim wording from the response
“• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 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
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 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 joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.

Verbatim wording from the response
“• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 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
Contact district nurses whenever they are involved in an adult’s care arrangements.

Verbatim wording from the response
“• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.”

Source location
Response from Kapital Care (UK) Limited
Page 1 · response
Published 8 December 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
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 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 improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.

Verbatim wording from the response
“• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 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
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 8 December 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
Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.

Verbatim wording from the response
“• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 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
Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.

Verbatim wording from the response
“• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 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
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.

Verbatim wording from the response
“• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient’s notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.”

Source location
Response from University College London Hospital
Page 4 · response
Published 8 December 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
Complete manual-handling, mobility-equipment and environmental assessments during initial visits.

Verbatim wording from the response
“• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.”

Source location
Response from Kapital Care (UK) Limited
Page 2 · response
Published 8 December 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
Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.

Verbatim wording from the response
“• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.”

Source location
Response from Kapital Care (UK) Limited
Page 2 · response
Published 8 December 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
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.

Verbatim wording from the response
“• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.”

Source location
Response from Central London Community Healthcare
Page 2 · response
Published 8 December 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
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 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
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.

Verbatim wording from the response
“• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.”

Source location
Response from University College London Hospitals
Page 5 · response
Published 8 December 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 hospital discharge information and discharge letters to identify care needs relevant to care delivery.

Verbatim wording from the response
“• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 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 organisational recording and documentation practices.

Verbatim wording from the response
“• Review of recording and documentation within the organisation.”

Source location
Response from Kapital Care
Page 2 · response
Published 8 December 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
Obtain the relevant discharge notification form before starting hospital-discharge care packages.

Verbatim wording from the response
“• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.”

Source location
Response from Kapital Care
Page 3 · response
Published 8 December 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
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.

Verbatim wording from the response
“• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.”

Source location
Response from City of Westminster
Page 2 · response
Published 8 December 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
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.

Verbatim wording from the response
“• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).”

Source location
Response from University College London Hospital
Page 5 · response
Published 8 December 2022
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
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.

Verbatim wording from the response
“We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.”

Source location
Response from University College London Hospitals
Page 6 · response
Published 8 December 2022
Open published response
10 Nov2022
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to ensure controlled and manageable discharge transfers between pressured care settings
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 14
1. Action
  Re-establish multidisciplinary integrated transfer-of-care hubs to coordinate admission avoidance, discharge and care reviews.
  Stated by Integrated Care Board (ICBStated completed
2. Action
  Optimise existing reablement capacity through a project with Prism and develop place-based collaboration, shared outcomes and coordinated hub arrangements.
  Stated by Integrated Care Board (ICBStated in progress
3. Action
  Develop data to optimise intermediate-care productivity and inform the integrated-care-system strategy and future commissioning.
  Stated by Integrated Care Board (ICBStated in progress
1. Action
  Reset discharge-to-assess working through a policy clarifying pathway roles and promoting returns home rather than long-term-care decisions in acute settings.
  Stated by Integrated Care Board (ICBStated completed
2. Action
  Develop accommodation-with-care-and-support specifications, including dementia provision.
  Stated by Integrated Care Board (ICBStated in progress
3. Action
  Commission community enablement services supporting up to 40 hospital discharges weekly.
  Stated by Integrated Care Board (ICBStated completed
4. Action
  Market-test additional regulated community enablement capacity to support 30 further weekly discharges.
  Stated by Integrated Care Board (ICBStated in progress
5. Action
  Develop virtual wards delivering coordinated hospital-level care at home, including digital monitoring and intravenous treatment.
  Stated by Integrated Care Board (ICBStated in progress
6. Action
  Train staff to identify suitable virtual-ward patients and increase occupancy of existing virtual-ward capacity.
  Stated by Integrated Care Board (ICBStated in progress
7. Action
  Establish and operate a system control centre with collaborative operational leadership, live data, risk oversight and system performance coordination.
  Stated by Integrated Care Board (ICBStated completed
8. Action
  Fund community beds, discharge lounges and ambulance hubs to reduce hospital flow and ambulance handover delays.
  Stated by Department of Health and Social CareStated completed
9. Action
  Make funding available to support adult social care, hospital discharge and timely transfer into community care.
  Stated by Department of Health and Social CareStated in progress
10. Action
  Work with NHS England to embed hospital discharge best practice through the 100-day challenge.
  Stated by Department of Health and Social CareStated in progress
11. Action
  Pilot new hospital discharge approaches through the Six National Discharge Frontunners.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

David John Morganti and 3 others · 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 report concerns several deaths involving delays in ambulance attendance and/or admission to Royal Cornwall Hospital, including deaths after falls, head injuries and a stroke. The principal concerns are the ongoing delays caused by ambulances being held at the hospital, limited intermediate and social care capacity, and the risk that unsafe or inadequately staffed discharge arrangements may worsen patients’ health and lead to readmission.

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 controlled and manageable discharge transfers between pressured care settings
Wider context from the report
“While there is an obvious need to discharge medically fit patients from Royal Cornwall Hospital, this has to be done in a controlled and manageable fashion. As set out above, GP representatives have drawn to my attention the extreme pressures primary care is currently under. Without more, it would seem to serve little purpose simply to transfer patients from one part of the system that is struggling to cope to a different part of the system that is equally challenged. ”
Source location
David John Morganti and 3 others · Prevention of Future Deaths report
Page 4 · 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
Re-establish multidisciplinary integrated transfer-of-care hubs to coordinate admission avoidance, discharge and care reviews.

Verbatim wording from the response
“has been re-established through our integrated transfer of care hubs (iToCHs) to prevent unnecessary delays for services which are not required and making best use of our valuable resources.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Optimise existing reablement capacity through a project with Prism and develop place-based collaboration, shared outcomes and coordinated hub arrangements.

Verbatim wording from the response
“Cornwall Foundation Trust (CFT) are currently leading a project with Prism to optimise use of existing reablement capacity. We plan to deliver the discharge to assess aim whereby most post-acute medical episode assessments take place in the persons home/usual place of residence. Our place based iToCHs already re-coordinate the requests for care review, both in admission avoidance and discharge and we are working to develop a model of place-based collaboration in reablement with shared local outcomes. The work seeks to accelerate the development of this place-based service with an overarching co-ordination hub in place and a complex discharge team. We are developing data to ensure we are optimising productivity in the services we have and to inform the ICS intermediate care strategy and future commissioning plans.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Develop data to optimise intermediate-care productivity and inform the integrated-care-system strategy and future commissioning.

Verbatim wording from the response
“Cornwall Foundation Trust (CFT) are currently leading a project with Prism to optimise use of existing reablement capacity. We plan to deliver the discharge to assess aim whereby most post-acute medical episode assessments take place in the persons home/usual place of residence. Our place based iToCHs already re-coordinate the requests for care review, both in admission avoidance and discharge and we are working to develop a model of place-based collaboration in reablement with shared local outcomes. The work seeks to accelerate the development of this place-based service with an overarching co-ordination hub in place and a complex discharge team. We are developing data to ensure we are optimising productivity in the services we have and to inform the ICS intermediate care strategy and future commissioning plans.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Reset discharge-to-assess working through a policy clarifying pathway roles and promoting returns home rather than long-term-care decisions in acute settings.

Verbatim wording from the response
“A joint commissioner’s day was held in November 2022 and agreed to reset the discharge to assess way of working in Cornwall, with a clear policy position which provides clarity around roles and responsibilities, addressed the high numbers of discharges on pathway 3 with an aim to support more people to return home from hospital as opposed to making long term care decision in an acute environment. There has been significant work completed on pathway 1, utilising voluntary sector support and this has seen a reduction of people waiting for services. There is also ongoing work to develop our specification for accommodation with care and support-which will include dementia.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Develop accommodation-with-care-and-support specifications, including dementia provision.

Verbatim wording from the response
“A joint commissioner’s day was held in November 2022 and agreed to reset the discharge to assess way of working in Cornwall, with a clear policy position which provides clarity around roles and responsibilities, addressed the high numbers of discharges on pathway 3 with an aim to support more people to return home from hospital as opposed to making long term care decision in an acute environment. There has been significant work completed on pathway 1, utilising voluntary sector support and this has seen a reduction of people waiting for services. There is also ongoing work to develop our specification for accommodation with care and support-which will include dementia.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Commission community enablement services supporting up to 40 hospital discharges weekly.

Verbatim wording from the response
“Intermediate care improvements: The ICB is currently commissioning community enablement capacity from Age UK, Humans Cornwall, a person-centred support brokerage and micro provider as well as CHAOS (Community Helping All Of Society) a domiciliary care”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 5 · response
Published 21 November 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
Market-test additional regulated community enablement capacity to support 30 further weekly discharges.

Verbatim wording from the response
“A market testing exercise is currently underway to commission additional regulated community enablement capacity to support a further 30 discharges per week from February 2023. Finally additional funding has been identified to provide enhanced intermediate care offer in community hospital beds.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 6 · response
Published 21 November 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
Develop virtual wards delivering coordinated hospital-level care at home, including digital monitoring and intravenous treatment.

Verbatim wording from the response
“Further mitigation can also be seen through our use of virtual wards. CFT are developing the Cornwall and Isles of Scilly @home service which seeks to co-ordinate community services to offer hospital level care at home, including digital monitoring and intravenous treatments at home (virtual wards). We currently have a respiratory ward; a care home ward and our frailty ward has just commenced. Current capacity is respiratory (25); frailty (5) and care homes (20).”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Train staff to identify suitable virtual-ward patients and increase occupancy of existing virtual-ward capacity.

Verbatim wording from the response
“We are working with the acute ‘emergency village’ in RCHT and with CFT bedded care services to optimise a step-down model of care into this service. Once training complete, staff will be regularly working with colleagues to identify people suitable for the virtual ward service and increasing occupancy of the existing capacity. We expect to see this steadily increase over the next 2 months.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 2 · response
Published 21 November 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
Establish and operate a system control centre with collaborative operational leadership, live data, risk oversight and system performance coordination.

Verbatim wording from the response
“System control centre: the ICB established a system control centre (SCC) through November to be fully operational by 1 December 2022. The SCC is led by the ICB chief nursing officer, senior responsible officer, with a clear collaborative action of system performance and risk through senior system level operational leadership and strategic oversight.”

Source location
Response from Cornwall and Isles of Scilly NHS
Page 3 · response
Published 21 November 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
Fund community beds, discharge lounges and ambulance hubs to reduce hospital flow and ambulance handover delays.

Verbatim wording from the response
“The NHS is also focussed on reducing the numbers of ambulance handover delays to hospitals. Alongside direct improvement support to the most challenged trusts, an additional £250 million was made available to enable the NHS to buy up beds in the community to safely discharge thousands of patients from hospital, and capital for discharge lounges and ambulance hubs. These measures have helped improve flow through hospitals and reduce ambulance handover delays. This is on top of the £500 million already invested last year.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 November 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
Make funding available to support adult social care, hospital discharge and timely transfer into community care.

Verbatim wording from the response
“We recognise that discharging people once they no longer need acute care improves their outcomes and reduces the risk of medical complications. To improve rates of safe hospital discharge and increase patient flow, the government is making available up to £2.8 billion this year and £4.7 billion in 2024-25 to support adult social care and discharge. This is alongside £700 million invested this winter, on top of £1.6 billion over the next two years, to support timely and safe discharge from hospital into the community.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 November 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
Work with NHS England to embed hospital discharge best practice through the 100-day challenge.

Verbatim wording from the response
“The Department is also working with NHSE on several important initiatives to embed best practice for discharging patients from hospitals. This includes the 100-day challenge, which is helping acute trusts improve patient flow based on using 10 best practice initiatives and the Six National Discharge Frontunners, which are piloting new approaches to discharge.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 November 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
Pilot new hospital discharge approaches through the Six National Discharge Frontunners.

Verbatim wording from the response
“The Department is also working with NHSE on several important initiatives to embed best practice for discharging patients from hospitals. This includes the 100-day challenge, which is helping acute trusts improve patient flow based on using 10 best practice initiatives and the Six National Discharge Frontunners, which are piloting new approaches to discharge.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 November 2022
Open published response
24 Oct2022
Herefordshire
Concerns raised1
1. Failure to establish current circumstances and input from other agencies 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.
Respondent positions 1
1. Position
  The service considered communication with other agencies unnecessary because no clinical reason or significant mental-health risk indicated information sharing.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustNo action considered necessary
AI-generated summary

Terri Ann Malone · Prevention of Future Deaths report

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

Report summary

Terri Ann Malone was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption. The concerns included treatment planning without direct contact by an experienced practitioner, discharge after a missed appointment and unanswered voicemail despite a lengthy wait, and discharge without establishing her current circumstances or other agencies’ involvement.

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 establish current circumstances and input from other agencies before discharge
Wider context from the report
“(3) A decision is made to discharge the patient without establishing their current circumstances and the current (if any) input from other agencies; full details of whom and consent to share information could be obtained during initial instructions taken by a more experience practitioner. ”
Source location
Terri Ann Malone · Prevention of Future Deaths report
Page 1 · 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
The service considered communication with other agencies unnecessary because no clinical reason or significant mental-health risk indicated information sharing.

Verbatim wording from the response
“I appreciate your concerns that the service did not communicate with others involved with the patient, however, our clinical view was that was not necessary. The Healthy Minds team were aware of the assessment from the NMHT that there were no significant mental health needs identified and that she was continuing to engage with Turning Point. Discussion about information sharing and confidentiality is discussed in all initial assessments, although due to the nature of the service, where the majority of referrals to Healthy Minds are self referrals, the service is reliant on the patient disclosing any other external services with whom they are in contact. If necessary information proportionate to the risk faced can be shared with other agencies, although there was no clinical reason to do so in the present instance.”

Source location
Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to complete a comprehensive risk assessment before discharge

Concerns raised3

Failure to contact emergency contacts or next of kin before or at discharge

Failure to arrange follow-up appointments before discharge

Failure to contact the patient after 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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Lack of escalation when assessment and discharge planning requests are not answered

Lack of assessment of section 117 needs for discharge

Insufficient assessment of the impact of autism diagnosis in discharge planning

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of Recovery and Discharge Plans to address online medication procurement risks

Concerns raised1

Lack of comprehensive planning for home leave and discharge from hospital

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices

Actions described in response 6

Respondent positions 1

Actions described in response 5

Respondent positions 1

Actions described in response 2

Respondent positions 2