2 Feb 2021 Michael Yemm · Prevention of Future Deaths report Norfolk
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Concerns raised 2
Failure to coordinate hospital discharge with the receiving care home View source Discharge of patients with medicines that the receiving care home cannot administer View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Norfolk and Norwich University Hospitals NHS Foundation Trust
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AI-generated summary
Michael Yemm · 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
Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to coordinate hospital discharge with the receiving care home
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back . He was also discharged on insulin which the home could not administer as they do not have trained nursing staff.
” Source location Michael Yemm · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge of patients with medicines that the receiving care home cannot administer
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff .
” Source location Michael Yemm · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that Mr Yemm was discharged without warning or without arrangements for insulin administration and supervision.
Verbatim wording from the response “Mr Yemm was started on insulin during the May 2020 admission. A District Nurse referral was made on discharge as Mr Yemm was unable to manage his own injections. On 17 June 2020 a “verbal handover” was given to Melton House including confirmation that the District Nurse referral had been completed in respect of Mr Yemm’s “insulin administration”.” Source location 2021-0024-Response-from-Norfolk-and-Norwich-University-Hospital-Redacted
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27 Jan 2021 Norma Bradbury · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Delays in transmitting discharge letters when timely GP involvement is required View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Norma Bradbury · 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
Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in transmitting discharge letters when timely GP involvement is required
Wider context from the report “Mrs Bradbury was discharged on 22.02.19.
The discharge letter to her GP instructed a review within 1 week to check Mrs Bradbury’s bloods and blood pressure, and to restart Losartan, and titrate the dose to her blood pressure. The consultant giving evidence at the hearing was clear that he expected this to have commenced within a week of discharge.
The evidence of Mrs Bradbury’s GP was that the discharge letter was not received until 25.02.19. The GP also advised that the delay in receiving discharge letters was very variable, between days and weeks.
I accept that in many cases the discharge letter is no more than a summary of an attendance and requires little or no further action on the part of the GP and the delay is of no consequence. However, where, as here, the discharging hospital requires GP involvement within 1 week of discharge a delay of 3 days in requesting or advising that involvement is not acceptable.
While it was not possible to determine any difference in outcome in Mrs Bradbury’s case there is a risk that such a delay would make a difference.
” Source location Norma Bradbury · Prevention of Future Deaths report
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14 Dec 2020 Elsie Yvonne Taylor · Prevention of Future Deaths report Black Country
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Concerns raised 2
Inaccurate wording in discharge notices about GP referral as an alternative to hospital admission View source Failure to include clinically relevant information in discharge notices View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Elsie Yvonne Taylor · 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
Elsie Yvonne Taylor, aged 68, fell at home on 15 September 2020, sustained rib fractures and a pneumothorax, and died later the same day after deteriorating in hospital. Concerns included incomplete recording of her reported decision to decline hospital admission and the advice given, lack of information about the consultation and deterioration symptoms, and no attempt to contact her GP or family despite her living alone.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inaccurate wording in discharge notices about GP referral as an alternative to hospital admission
Wider context from the report “(5) The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission ;
” Source location Elsie Yvonne Taylor · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to include clinically relevant information in discharge notices
Wider context from the report “(5) The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission;
” Source location Elsie Yvonne Taylor · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
Verbatim wording from the response “Response
During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts’ expected standard of completing and checking documentation.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge form advised contacting or attending the GP; it did not indicate that the patient had been referred.
Verbatim wording from the response “Response
The box ticked on the discharge form states that the patient had been advised to contact or attend her GP practice. If a referral had been made on behalf of the patient one of the boxes at the top of the form would have been ticked.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A discharge sheet provided safety-netting information, so it was not correct that no relevant information or consultation outcome was left.
Verbatim wording from the response “Response
A discharge sheet was left with the patient, which detailed that the patient was to contact the GP or in the case of an emergency to call 999/111. The paramedic has confirmed that there was no family present but there was neighbour in attendance throughout the whole consultation. The neighbour was shown the bruise on the patient ribs and she informed the crew that she would stay with the patient for some time to keep an eye on her.” Source location 2020-0281-Response-from-West-Midlands-Ambulance-Service-REDACTED
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11 Nov 2020 Margaret Lilian SALES · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to communicate required follow-up arrangements to GPs at discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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AI-generated summary
Margaret Lilian SALES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Lilian Sales, who was frail and had several comorbidities, was admitted to hospital on 13 December 2019 and died on 4 January 2020 after her health deteriorated. Concerns included incomplete records, difficulties contacting on-call medical staff, and a failure to request GP monitoring of her capillary blood glucose after discharge. The inquest concluded that she died from aspiration pneumonia, the cause of which was not clear from the evidence.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate required follow-up arrangements to GPs at discharge
Wider context from the report “3. On a previous discharge from hospital, it was noted Mrs Sales had been referred to the Home Enteral Nutrition service for monitoring and follow up and that in situations such as this, requests will be placed with the GP. However, no such request had been placed with the GP. The Discharge Letter in fact stated: "Actions for the GP: No recommendations" . As a result, the GP did not monitor Mrs Sales’ capillary blood glucose following discharge.
” Source location Margaret Lilian SALES · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current practice and guidelines did not indicate that the Trust should recommend home blood glucose monitoring to the GP.
Verbatim wording from the response “At this Trust our Diabetic Specialist Nurses would ensure that the GP was made aware that they had to ensure blood glucose monitoring was done at home if a patient had been put on either Gliclazide or Insulin during an admission. It is true to say that if Mrs Sales had had her blood glucose monitored at home between 6th November and 13 December 2019 her subsequent illness would have become apparent sooner, but in terms of current practice and guidelines there was no indication for us to make such a recommendation to the GP.” Source location 2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The system remains robust, so no further action is proposed regarding home blood glucose monitoring advice.
Verbatim wording from the response “I have heard from our consultant ████████ and also Legal Services Manager that we had not expected this issue to be raised at the inquest, if so we would have taken the opportunity to supply evidence on this point for you at the time from one of our Dietetics or Diabetes team members who deal regularly with referrals to Fresnius and the General Practitioners in Norfolk, Cambridgeshire and Lincolnshire. With hindsight, perhaps our RCA could have gone into more detail on that point; but presently we think that the system remains robust and with no discourtesy intended do not propose to take any further action on this point at the present time.” Source location 2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
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23 Oct 2020 Sean Robert Steven Owen · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Lack of quality assurance of discharge summary letters View source Discharge summary letters failing to communicate significant clinical risks and incidents View source
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Pennine Care NHS Foundation Trust
Check and discuss new trainees’ admission and discharge summaries during their first month, with senior-doctor review before discharge.
View source
Pennine Care NHS Foundation Trust
Incorporate documentation review into trainees’ weekly supervision.
View source
Pennine Care NHS Foundation Trust
Audit the revised admission and discharge summary process.
View source
Pennine Care NHS Foundation Trust
Provide all new medical trainees with training on admission and discharge summary standards and processes.
View source
Pennine Care NHS Foundation Trust
Issue new trainees laptops and require admission and discharge summaries to be maintained as live documents throughout patients’ admissions.
View source See 2 more actions
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AI-generated summary
Sean Robert Steven Owen · 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
Sean Robert Steven Owen had a history of treatment-resistant paranoid schizophrenia and was recognised as being at significant risk if non-compliant with medication. After medication monitoring arrangements broke down, he self-inflicted a penetrating neck injury on 3 June 2019 and died on 14 June 2019 from his injuries and a chest infection. The report raised concerns that his discharge letter omitted significant information about overdoses, suicidal thoughts and the risks associated with medication non-compliance, and that there was no quality assurance system for such letters.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of quality assurance of discharge summary letters
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care . The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician . It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.
” Source location Sean Robert Steven Owen · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge summary letters failing to communicate significant clinical risks and incidents
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission ; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance .
” Source location Sean Robert Steven Owen · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check and discuss new trainees’ admission and discharge summaries during their first month, with senior-doctor review before discharge.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate documentation review into trainees’ weekly supervision.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the revised admission and discharge summary process.
Verbatim wording from the response “The revised process will be subject to an audit.” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all new medical trainees with training on admission and discharge summary standards and processes.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue new trainees laptops and require admission and discharge summaries to be maintained as live documents throughout patients’ admissions.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
30 Sep 2020 Joseph Michael Cheetham · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in putting care packages in place for medically optimised patients View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
View source
NHS Greater Manchester Integrated Care Board
Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
View source
NHS Greater Manchester Integrated Care Board
Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
View source
NHS Greater Manchester Integrated Care Board
Review community-based capacity to ensure discharge pathways have the correct types of capacity.
View source See 1 more action
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AI-generated summary
Joseph Michael Cheetham · 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
Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in putting care packages in place for medically optimised patients
Wider context from the report “2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place . One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place . To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge.
” Source location Joseph Michael Cheetham · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
Verbatim wording from the response “This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3.6billion funding for winter, an extra £588million was confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
Verbatim wording from the response “As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within Greater Manchester. The purpose of the guidance is to improve the flow of all patients being discharged from acute care and to help ensure patients’ needs are assessed in the home or usual place of residence – not in the hospital. If it is not” Source location 2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
Verbatim wording from the response “The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.” Source location 2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review community-based capacity to ensure discharge pathways have the correct types of capacity.
Verbatim wording from the response “The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.” Source location 2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.
Verbatim wording from the response “It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. NHS providers are expected to begin planning for a person’s discharge at the point of admission, which should include practical arrangements, care requirements and where the person is being discharged to. The hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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18 Sep 2020 PAULINE VIOLET OAKLEY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to assess the safety or suitability of the home and appliances as part of hospital discharge planning View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PAULINE VIOLET OAKLEY · 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
Pauline Oakley fell onto an electric heater at her home on 3 April 2020, causing a fire. She sustained burns covering 60% of her body and died later that day in hospital. The concerns included the absence of assessments of the safety and suitability of her home and appliances, and the apparent lack of monitoring of the building’s fire alarm.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess the safety or suitability of the home and appliances as part of hospital discharge planning
Wider context from the report “(1) There was no assessment of the safety or suitability of Pauline Oakley’s flat, or the appliances within the flat arranged by the NHS Trust Foundation responsible for her discharge home as part of the hospital discharge plan . The evidence was that she had fallen on a modern electric heater, with a built in safety mechanism, there would have been no fire.
” Source location PAULINE VIOLET OAKLEY · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure the multidisciplinary team and Social Services are informed when concerns about a vulnerable patient’s home safety are raised or suspected.
Verbatim wording from the response “I have discussed this tragic case with the practice clinical team. We all have a duty of care with respect to adult safeguarding when caring for vulnerable patients. In this regard, we are responsible for raising concerns about the adequacy or safety of the home environment to the relevant authorities. Whilst no such concerns were raised with us in this case, the GP practice team has agreed that, in cases like this, where a concern is raised or suspected we will ensure the multi-disciplinary team and Social Services are made aware, especially if they have specific (and relevant) areas of responsibility, such as fire safety risk assessments.” Source location 2020-0304-Response-from-GP-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prompt the Care Navigator or Social Worker at monthly multidisciplinary meetings to ensure appropriate fire-safety checks are implemented.
Verbatim wording from the response “The practice has a longstanding monthly Integrated Care Multidisciplinary Team Meeting which is attended by the Practice GPs, the extended primary care team, the social worker and the palliative care team. We reviewed our practise with regard to concerns about fire safety at the Integrated Care Meeting which immediately followed the Inquest and again at the weekly Practice Meeting on Friday 29th January 2021. It was agreed that Clinicians could prompt the Care Navigator or the Social” Source location 2020-0304-Response-from-GP-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for environmental risk assessments after discharge lay with the Reablement Team within the London Borough of Tower Hamlets.
Verbatim wording from the response “████████, Legal Affairs Manager was present at the Inquest and informed you that it was her understanding that responsibility for environmental risk assessment following Ms Oakley’s discharge from hospital, would lie with the Reablement Team. The Reablement Team falls within the remit of the London Borough of Tower Hamlets. The Trust understands that the Reablement Team were providing Ms Oakley with regular support following her discharge in order to help her with everyday tasks and ensure that she could live as independently as possible.” Source location 2020-0304-Response-from-East-London-NHS-Foundation-Trust_Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospital discharge planning, including functional assessment before discharge, is the hospital team’s responsibility; primary care is not involved.
Verbatim wording from the response “In respect of The Royal London Hospital (Barts Health NHS Trust), where Ms Oakley was admitted and discharged, it is usual practice for a patient to be deemed fit from both a medical and social/functional perspective before they are discharged home (the Coroner will no-doubt hear from the relevant Trust in this regard). This would be part of the assessment by the hospital medical team and by a hospital Multi-Disciplinary Team consisting, more likely than not, of an Occupational Therapist, Physiotherapist and Social Worker in order to prepare a hospital discharge plan. The GP (Primary Care Provider) is not involved in hospital discharge planning. However, we would normally receive a discharge summary from the hospital with a brief medical summary, information about medication on discharge, and any medical follow up required.” Source location 2020-0304-Response-from-GP-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Occupational therapy assesses functional safety in the home but does not assess the safety or adequacy of electrical appliances.
Verbatim wording from the response “To the best of my knowledge and belief, an Occupational Therapy assessment is a functional assessment (looking, for example, at the need for hand rails or ramps, or having tools in place to help the patient function better or more safely in the home environment). It would not go as far as to assess the safety of electrical appliances, such as the age or adequacy of the electrical heater in this case. Whilst it is correct to say an Occupational Therapy assessment can be initiated by the GP, Mrs Oakley was returning to an integrated, multi-disciplinary umbrella of care, including the Occupational Therapy Reablement Team provided by Tower Hamlets Local Authority/Social Services. Therefore in this scenario there was no further need for a GP referral for an Occupational Therapy assessment to be made as this was already in place.” Source location 2020-0304-Response-from-GP-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further GP occupational therapy referral was needed because the patient was already under an integrated care arrangement including the local-authority reablement team.
Verbatim wording from the response “To the best of my knowledge and belief, an Occupational Therapy assessment is a functional assessment (looking, for example, at the need for hand rails or ramps, or having tools in place to help the patient function better or more safely in the home environment). It would not go as far as to assess the safety of electrical appliances, such as the age or adequacy of the electrical heater in this case. Whilst it is correct to say an Occupational Therapy assessment can be initiated by the GP, Mrs Oakley was returning to an integrated, multi-disciplinary umbrella of care, including the Occupational Therapy Reablement Team provided by Tower Hamlets Local Authority/Social Services. Therefore in this scenario there was no further need for a GP referral for an Occupational Therapy assessment to be made as this was already in place.” Source location 2020-0304-Response-from-GP-Redacted
Open published response
4 Aug 2020 Pauline Russell · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to ensure discharge instructions are accessible and understood by patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
James Paget University Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
James Paget University Hospitals NHS Foundation Trust
Review admission and discharge documentation across the Trust to identify required changes.
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James Paget University Hospitals NHS Foundation Trust
Amend admission and discharge documentation to include literacy checks, support requirements and signposting to the admissions booklet.
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James Paget University Hospitals NHS Foundation Trust
Launch and cascade the amended documentation through ward managers at the Clinical Leaders Event.
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James Paget University Hospitals NHS Foundation Trust
Audit compliance with the amended admission and discharge documentation monthly, beginning with results available at the end of October.
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AI-generated summary
Pauline Russell · 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
Pauline Russell, a poorly controlled diabetic, was discharged from hospital after her insulin dose was increased, but she and her husband could not read the written discharge instructions. She subsequently received a higher incorrect insulin dose, became unresponsive in a hypoglycaemic coma, and died from aspiration pneumonia. The principal concern was that the hospital did not check patients’ literacy or provide discharge instructions in an accessible alternative format.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure discharge instructions are accessible and understood by patients
Wider context from the report “No one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that ████████ could read and understand the discharge summary . The inquest was 8 months after Mrs Russell’s death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are , eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again.
” Source location Pauline Russell · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review admission and discharge documentation across the Trust to identify required changes.
Verbatim wording from the response “Following your inquest, the hospital’s Director of Nursing instigated a review of the admission and discharge documentation used across the Trust to identify any required changes.” Source location 2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend admission and discharge documentation to include literacy checks, support requirements and signposting to the admissions booklet.
Verbatim wording from the response “As a result of this review, the admission and discharge documentation has been amended to include additional checks relating to literacy support. The Multi-Disciplinary Care Record now requires staff to check whether the patient is able to read English and if any additional support is required. The ‘Discharge Checklist’ also highlights language and literacy skills to the completing staff and signposts them to the new admissions booklet. Please see enclosed copy of the amended documentation. The updated documentation has been” Source location 2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and cascade the amended documentation through ward managers at the Clinical Leaders Event.
Verbatim wording from the response “As a result of this review, the admission and discharge documentation has been amended to include additional checks relating to literacy support. The Multi-Disciplinary Care Record now requires staff to check whether the patient is able to read English and if any additional support is required. The ‘Discharge Checklist’ also highlights language and literacy skills to the completing staff and signposts them to the new admissions booklet. Please see enclosed copy of the amended documentation. The updated documentation has been” Source location 2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the amended admission and discharge documentation monthly, beginning with results available at the end of October.
Verbatim wording from the response “shared with ward managers to cascade accordingly and the documentation will be formally launched at the Clinical Leaders Event on 7 October 2020. To ensure compliance, the Trust will carry out a monthly audit of this documentation with the first results available at the end of October.” Source location 2020-0149-Response-from-James-Paget-University-Hospitals-NHS-Foundation-Trust_Redacted-1.pdf
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30 Jul 2020 Reginald Collins · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in discharge via Adult Social Care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Reginald Collins · 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
Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and nationally.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in discharge via Adult Social Care
Wider context from the report “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him.
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally.
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.
” Source location Reginald Collins · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain cross-system work to improve hospital discharge.
Verbatim wording from the response “As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.
Verbatim wording from the response “As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.
Verbatim wording from the response “sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
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26 Jun 2020 Gary Etherington · Prevention of Future Deaths report Inner South London
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Concerns raised 3
Inadequate discharge plan communicated to GP View source Failure to take and consider relevant patient history before discharge View source Failure to properly assess suicidal symptoms and risks before discharge View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Gary Etherington · 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
Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate discharge plan communicated to GP
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP .
” Source location Gary Etherington · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to take and consider relevant patient history before discharge
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP.
” Source location Gary Etherington · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly assess suicidal symptoms and risks before discharge
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide , delusions of people being present, their cause and relation to drug misuse, or the risks to ████████ , about which there was an inadequate plan communicated to the GP.
” Source location Gary Etherington · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.
Verbatim wording from the response “Turning to your second concern that Mr Etherington was discharged without adequate consideration of his symptoms and communication to his general practitioner, I have ensured that all our primary care teams (PCP), who are the gateway to our secondary mental health services, write comprehensive letters to general practitioners addressing the specific issues raised by the general practitioner including outlining the outcome of assessments and treatment advice.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.