27 Apr 2020 Evelyn Ross · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in arranging suitable community care packages for discharge View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Evelyn Ross · 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
Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.
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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 arranging suitable community care packages for discharge
Wider context from the report “2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community .
” Source location Evelyn Ross · 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 Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
Verbatim wording from the response “During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.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 adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Verbatim wording from the response “In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge” Source location 2020-0106-Response-from-Manchester-University-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 Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Verbatim wording from the response “As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
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. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.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 Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
Verbatim wording from the response “In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
Verbatim wording from the response “centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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9 Mar 2020 Rebecca Jane Hursey · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure to consider bespoke placements early for complex patients View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Rebecca Jane Hursey · 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
Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.
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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 consider bespoke placements early for complex patients
Wider context from the report “5. That bespoke placements are considered early in the discharge process for complex patients .
” Source location Rebecca Jane Hursey · Prevention of Future Deaths report
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15 Jan 2020 Daniel Jeffrey Moran · Prevention of Future Deaths report Manchester West
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Concerns raised 2
Failure to consider admission circumstances and current risks in self-discharge decisions View source Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Daniel Jeffrey Moran · 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 Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.
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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 consider admission circumstances and current risks in self-discharge decisions
Wider context from the report “4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale.
” Source location Daniel Jeffrey Moran · 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 Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
Wider context from the report “4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale .
” Source location Daniel Jeffrey Moran · Prevention of Future Deaths report
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11 Nov 2019 Antonis Tofali Hannides · Prevention of Future Deaths report Avon
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Concerns raised 1
Lack of a formal system for seeing patients who reattend unexpectedly after discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Spire Bristol Hospital
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
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Antonis Tofali Hannides · 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
Antonis Tofali Hannides died on 29 March 2019 from liver and heart disease after undergoing hernia repair and subsequently reattending hospital with confusion. Concerns included the lack of a formal system for managing unexpected reattendance after discharge, inadequate documentation, and failure to inform his consultant immediately.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a formal system for seeing patients who reattend unexpectedly after discharge
Wider context from the report “No formal system at Spire Bristol for
1) Seeing patients who reattend unexpectedly after discharge;
2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance;
3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge.
” Source location Antonis Tofali Hannides · 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 Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
Verbatim wording from the response “In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannides’ case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients’ consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_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 Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
Verbatim wording from the response “It is anticipated that some patients who have undergone treatment at a Spire Hospital may contact the Hospital with enquiries about their care after discharge. As such, Spire Healthcare has an Admission and Discharge policy (in place at the time of Mr Hannides’ admission) which outlines a number of key steps that must take place as part of any patients’ discharge planning process, to ensure that patients are supported after they leave hospital and are aware of how to seek advice if they have concerns.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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29 Oct 2019 Charlotte Grace · Prevention of Future Deaths report Cumbria
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Concerns raised 2
Failure to routinely involve agencies receiving discharged patients in the discharge process View source Failure to routinely involve supportive families or friends in the discharge process View source
Linked response
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.
View source
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.
View source
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.
View source
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Hold weekly interface meetings to discuss complex cases and escalate discharge-meeting non-attendance to clinical leads and, where persistent, the Associate Director.
View source
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.
View source See 2 more actions
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Charlotte Grace · 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
Charlotte Grace was discharged from hospital on 20 September 2018 and was found hanging the following evening; the inquest recorded that she took her life by hanging on 21 September 2018. The principal concern was that the Home Treatment Team and her nominated next of kin were not invited to the discharge meeting, despite her being at chronic high risk of suicide and being referred for follow-up care.
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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 routinely involve agencies receiving discharged patients in the discharge process
Wider context from the report “(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted . 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting . I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process.
” Source location Charlotte Grace · 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 Failure to routinely involve supportive families or friends in the discharge process
Wider context from the report “(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted. 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting. I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process .
” Source location Charlotte Grace · 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 Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.
Verbatim wording from the response “1. A learning review was carried out following the investigation on 16th November 2018 in which it was discussed that attendance of significant clinicians involved with the patient’s care at the time and those responsible for providing future care would be best practice. The learning review suggested that where geographical barriers or workloads prevent face to face attendance at meetings, teleconferencing / videoconferencing could be used as an alternative.” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.
Verbatim wording from the response “2. Where geographical restrictions exist, teams utilise phone dial in and will move to Skype facilities within the next 3 months as part of the Trust’s IT mobilisation planning and roll out.” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.
Verbatim wording from the response “4. In order to ensure that the relevant teams/services are invited to discharge meetings, this is monitored as per the Trust’s discharge flow chart. This flow chart provides prompts for teams to be invited and indicates that meeting arrangements will be agreed at least 2 days ahead unless urgent. Where attendance is not possible the flow chart states that this should be escalated to team leaders. Although this flow chart was in existence at the time of the incident, it is apparent that it was not being used consistently however, following a safer discharge project staff have been reminded to utilise this. The project includes a commitment to ensure that an agreed follow up is in place within 48 hours of discharge.” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly interface meetings to discuss complex cases and escalate discharge-meeting non-attendance to clinical leads and, where persistent, the Associate Director.
Verbatim wording from the response “5. In addition to the above, weekly interface meetings take place which incorporate all community and inpatient services and ensure that complex cases are discussed alongside discharge meetings. If issues with attendance are identified, this is raised and actioned with clinical leads. Where regular non-attendance is identified, this is now being escalated to the Associate Director of the Clinical Business Unit.” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.
Verbatim wording from the response “6. In order to monitor the discharge process the Trust use a safer discharge audit. This audit is used on each ward and monitors the following information:” Source location 2019-0402-Response-by-Cumbria-NHS-Trust
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8 Oct 2019 Mary Jane Chapman · Prevention of Future Deaths report Cheshire
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Concerns raised 3
Lack of guidance for arranging and communicating critical post-discharge investigations View source Failure to clearly define responsibilities and timings in the discharge process View source Failure to demonstrate effective discharge communications View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Nuffield Health
Rewrite the national discharge policy to clarify multidisciplinary roles, responsibilities, discharge scenarios and arrangements for critical post-discharge investigations.
View source
Nuffield Health
Test and roll out an electronic quality-management audit across hospitals to monitor discharge-process effectiveness and patient experience.
View source
Nuffield Health
Communicate consultants’ responsibilities for contemporaneous documentation and discharge-related communication with nursing staff and GPs.
View source
Nuffield Health
Contact GPs by telephone, in addition to sending discharge summaries, when urgent action is required.
View source
Nuffield Health
Use secure electronic discharge-summary delivery to provide GP surgeries with heightened assurance of receipt within 48 hours.
View source
Nuffield Health
Advance a quality-improvement plan for standardised discharge systems, processes and collaborative working with GPs.
View source See 3 more actions
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Mary Jane Chapman · 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
Mary Jane Chapman underwent elective knee replacement surgery and was discharged with a low platelet count, but a required follow-up blood test was not arranged. She was later admitted with a dangerously low platelet count and died on 4 March 2018 from a large myocardial infarction caused by coronary artery thrombosis associated with catastrophic antiphospholipid syndrome. The principal concerns related to unclear discharge responsibilities and procedures, inadequate communication and documentation of critical follow-up investigations, and insufficient evidence that subsequent changes had improved these processes.
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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 guidance for arranging and communicating critical post-discharge investigations
Wider context from the report “2) There is no clear local or Nuffield-wide guidance document or policy on how the need for critical post-discharge investigations should be arranged or communicated, or by whom or when ;
” Source location Mary Jane Chapman · 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 Failure to clearly define responsibilities and timings in the discharge process
Wider context from the report “1) Although a Nuffield-wide ‘discharge policy’ has been created, the document is lengthy, unwieldy and generic. It does not clearly define who is responsible for doing what, or when, as part of the discharge process and there is no clear local or Nuffield-wide guidance document or policy that achieves this ;
” Source location Mary Jane Chapman · 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 Failure to demonstrate effective discharge communications
Wider context from the report “3) In respect of (1) and (2) above there was no evidence at the inquest that clinical and nursing staff are now aware of their individual roles and responsibilities in the discharge process, other than as part of a new induction process, which self-evidently only captures new staff. Equally, despite 18 months having elapsed since the death, there was no evidence at the inquest to demonstrate that such changes as have been implemented have improved the quality, accuracy and robustness of discharge communications ;
” Source location Mary Jane Chapman · 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 Rewrite the national discharge policy to clarify multidisciplinary roles, responsibilities, discharge scenarios and arrangements for critical post-discharge investigations.
Verbatim wording from the response “1) The revised Nuffield Health Policy (Appendix B) is rewritten paying particular attention to clarity of role and responsibilities associated with different professionals within the multidisciplinary team, with regard to the patient discharge process. The process itself has greater clarity and considers all scenarios that may present for patients using Nuffield Health services.” Source location 2019-0360-Response-by-Nuffield-Health
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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 Test and roll out an electronic quality-management audit across hospitals to monitor discharge-process effectiveness and patient experience.
Verbatim wording from the response “3) The role & responsibilities of all professionals working within the multidisciplinary clinical team are clear within the revised policy and an audit process, which is currently being tested, will be used across all hospitals to monitor the efficacy of the process and the patient experience. This audit is on our electronic Quality Management System (QMS). The list of questions that make up the audit are attached at Appendix C but please note that this does not show the on-line format which is user-friendly with clear headings. Section 7 onwards of the audit is of particular relevance” Source location 2019-0360-Response-by-Nuffield-Health
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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 Communicate consultants’ responsibilities for contemporaneous documentation and discharge-related communication with nursing staff and GPs.
Verbatim wording from the response “4) Every medical practitioner working within Nuffield Hospitals received a communication:” Source location 2019-0360-Response-by-Nuffield-Health
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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 Contact GPs by telephone, in addition to sending discharge summaries, when urgent action is required.
Verbatim wording from the response “Immediately following Mary’s death, a local investigation took place at the Hospital with significant changes to mitigate future risk. This included the introduction of an additional step in Nuffield’s” Source location 2019-0360-Response-by-Nuffield-Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use secure electronic discharge-summary delivery to provide GP surgeries with heightened assurance of receipt within 48 hours.
Verbatim wording from the response “Another key development in the Hospital was the introduction of electronic issue of discharge summaries via a secure portal, to give heightened assurance that information is received into GP surgeries within 48hrs of patient discharge. This system is in place in a small number of Nuffield Hospitals and we are looking to extend across all 31 locations. We now recognise further opportunities to improve quality and consistency of the discharge process through standardisation of systems, process and collaborative working with GP’s, which we are taking forward in our Quality Improvement Plan.” Source location 2019-0360-Response-by-Nuffield-Health
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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 Advance a quality-improvement plan for standardised discharge systems, processes and collaborative working with GPs.
Verbatim wording from the response “Another key development in the Hospital was the introduction of electronic issue of discharge summaries via a secure portal, to give heightened assurance that information is received into GP surgeries within 48hrs of patient discharge. This system is in place in a small number of Nuffield Hospitals and we are looking to extend across all 31 locations. We now recognise further opportunities to improve quality and consistency of the discharge process through standardisation of systems, process and collaborative working with GP’s, which we are taking forward in our Quality Improvement Plan.” Source location 2019-0360-Response-by-Nuffield-Health
Open published response
24 Sep 2019 Mr Francis Hodge · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to provide adequate post-operative discharge advice about warning symptoms View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Francis Hodge · 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
Mr Francis Hodge died on 16 November 2018 at University Hospital Lewisham from a perforated colon, seven days after elective laparoscopic repair of multiple incisional hernias. Concerns were raised that he received inadequate discharge advice and was not told to seek help for breathlessness or persistent pain. It was also reported that no patient information leaflet existed for this type of surgery.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide adequate post-operative discharge advice about warning symptoms
Wider context from the report “(1) At inquest I was told that on discharge Mr Hodge was given inadequate discharge advice . He was advised to rest as much as possible and that if he were to remain in severe pain in a week's time he should return.
(2) The consultant who undertook the surgery explained that such discharge advice was not what should have been provided to a patient following this surgery . The patient should have been told to be concerned about and to look out for: breathlessness, pus or redness, and / or pain which would not settle .
(3) Mr Hodge was suffering breathless the night before his collapse and pain which would not settle. He however, did not want to seek medical advice. I am told, because he was following what he had been told to do on discharge.
” Source location Mr Francis Hodge · Prevention of Future Deaths report
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28 Aug 2019 Amir Siman-Tov · Prevention of Future Deaths report London (West)
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Concerns raised 2
Failure to provide detailed written clinical information and directions on discharge View source Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Amir Siman-Tov · 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
Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide detailed written clinical information and directions on discharge
Wider context from the report “8. On discharge Mr Siman-Tov in the early evening of the 16ᵗʰ February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital . The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at risk .
” Source location Amir Siman-Tov · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
Wider context from the report “7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC . Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment.
” Source location Amir Siman-Tov · Prevention of Future Deaths report
Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of discharge planning to share risk information with GPs and families View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” Source location Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
Open source report
24 Jun 2019 Lewis James Doyle · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to send discharge letters to all current medical attendants View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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AI-generated summary
Lewis James Doyle · 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
Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.
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 send discharge letters to all current medical attendants
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Source location Lewis James Doyle · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Verbatim wording from the response “Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP. The discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this – in line with recommendations from the Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB).¹” Source location 2019-0214-Response-from-NHS-England-and-NHS-Improvement
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Verbatim wording from the response “I am advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared.” Source location 2019-0214-Response-by-Department-of-Health-and-Social-care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.