Recurring concern

Unreliable hospital discharge processes

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First reported 30 Jan 2013•Latest report 10 Jun 2026

Definition

What this concern includes

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

Not included

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

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

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care48

NHS England20

University Hospitals Sussex NHS Foundation Trust9

Essex Partnership University NHS Foundation Trust8

Manchester University NHS Foundation Trust8

Barts Health NHS Trust7

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

NHS Greater Manchester Integrated Care Board6

Tameside and Glossop Integrated Care NHS Foundation Trust6

Betsi Cadwaladr University LHB5

Kent and Medway Mental Health NHS Trust5

Pennine Care NHS Foundation Trust5

Royal London Hospital5

Stockport NHS Foundation Trust5

Concerns and responses across reports

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

14 Mar2018
Manchester South
Concerns raised1
1. Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review the case with the practice to identify further learning.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
2. Action
  Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
AI-generated summary

Peter STOJILJKOVIC · 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

Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.

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 communicate with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report
“1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community; 2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. 4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. 5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community. ”
Source location
Peter STOJILJKOVIC · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the case with the practice to identify further learning.

Verbatim wording from the response
“1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning.”

Source location
2018-0077-Response-by-NHS-England
Page 1 · response
Published 16 June 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.

Verbatim wording from the response
“4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”

Source location
2018-0077-Response-by-NHS-England
Page 2 · response
Published 16 June 2018
Open published response
14 Mar2018
Manchester South
Concerns raised2
1. Failure to accurately transcribe significant individual results into discharge letters
2. Failure to include a complete set of blood results in discharge letters
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Janet Hall · Prevention of Future Deaths report

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

Report summary

Janet Hall died after a series of hospital admissions and attendances, with the medical cause described as acute left ventricular failure and B Cell lymphoma on a background of ischaemic heart disease. A principal concern was that an Emergency Department discharge letter stated that blood tests were normal, although her full blood count was abnormal, and that discharge letters did not routinely include complete blood results, limiting opportunities for GPs to identify trends.

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 accurately transcribe significant individual results into discharge letters
Wider context from the report
“Following Mrs Hall’s attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text ‘Bloods and ECG all normal’. The evidence before the court was that contrary to this statement, Mrs Hall’s full blood count was, in fact, abnormal, with a slightly low haemoglobin at 96 grams / litre. ████████ Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results. In addition to increasing the chances for errors of the sort that occurred in this case, it is a matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis. ”
Source location
Janet Hall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to include a complete set of blood results in discharge letters
Wider context from the report
“Following Mrs Hall’s attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text ‘Bloods and ECG all normal’. The evidence before the court was that contrary to this statement, Mrs Hall’s full blood count was, in fact, abnormal, with a slightly low haemoglobin at 96 grams / litre. ████████ Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results. In addition to increasing the chances for errors of the sort that occurred in this case, it is a matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis. ”
Source location
Janet Hall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Feb2018
Suffolk
Concerns raised2
1. Failure to prescribe safe quantities of discharge medication for patients at risk of stockpiling medication
2. Failure to record the quantities of discharge medication issued
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Assess medications prescribed on discharge across the Trust.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

Rachel Holly Edwards · 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

Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

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 prescribe safe quantities of discharge medication for patients at risk of stockpiling medication
Wider context from the report
“The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’. ”
Source location
Rachel Holly Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record the quantities of discharge medication issued
Wider context from the report
“The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’. ”
Source location
Rachel Holly Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Assess medications prescribed on discharge across the Trust.

Verbatim wording from the response
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust. In the majority of situations an individual’s recovery into the community is supported by a period of care with the Crisis Resolution and Home Treatment team.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 1 · response
Published 30 April 2024
Open published response
29 Jan2018
Inner South London
Concerns raised1
1. Discharge from hospital without follow-up
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Discharge without follow-up was considered sufficient because the family knew how to access crisis support if required.
  Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Michael Vukovic · 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 Vukovic, who was suffering psychosis, jumped from a second- or third-floor balcony on 8 July 2017 and sustained an L1 vertebral fracture. He suffered a cardiac arrest and hypoxic brain damage after admission to hospital, and died on 11 July 2017. The principal concerns were that he was not seen by the Home Treatment Team, that follow-up with a drug and alcohol service was not checked, and that he was discharged without follow-up.

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
Discharge from hospital without follow-up
Wider context from the report
“My specific concerns are as follows: (1) ████████ evidence that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline. (3) The result was that Mr Vukovic was discharged from hospital without follow up. ”
Source location
Michael Vukovic · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Discharge without follow-up was considered sufficient because the family knew how to access crisis support if required.

Verbatim wording from the response
“(3) Mr Vukovic was discharged from hospital without follow up.”

Source location
Michael-Vukovic-Response
Page 2 · response
Published 8 June 2018
Open published response
22 Jan2018
London (East)
Concerns raised2
1. Failure to assign responsibility for chasing test results before discharge
2. Failure to chase outstanding test results before discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Caliel Arlington SMITH-KWAMI · 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

Caliel Arlington Smith-Kwami suffered a profound hypoglycaemic episode around 28 hours after birth and later died on 17 August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. He was discharged before key test results were obtained, and concerns included failures to notify clinicians that results were delayed or available, unclear responsibility for chasing results, and a missed opportunity to involve community midwives.

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 assign responsibility for chasing test results before discharge
Wider context from the report
“(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge. ”
Source location
Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to chase outstanding test results before discharge
Wider context from the report
“(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge. ”
Source location
Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jan2018
Brighton and Hove
Concerns raised1
1. Lack of a coherent urology enhanced recovery discharge planning protocol
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.
  Stated by East Sussex Healthcare NHS TrustStated planned
2. Action
  Review the urology discharge process and maintain a discharge protocol for enhanced recovery patients.
  Stated by East Sussex Healthcare NHS TrustStated completed
Respondent positions 1
1. Position
  A urology enhanced-recovery discharge protocol was already in place, and the discharge process had been reviewed.
  Stated by East Sussex Healthcare NHS TrustDisputes the concern
AI-generated summary

Barry John TUCKER · Prevention of Future Deaths report

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

Report summary

The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a coherent urology enhanced recovery discharge planning protocol
Wider context from the report
“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients. ”
Source location
Barry John TUCKER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

Verbatim wording from the response
“Trust Response There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 5 · response
Published 8 March 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the urology discharge process and maintain a discharge protocol for enhanced recovery patients.

Verbatim wording from the response
“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 7 · response
Published 8 March 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
A urology enhanced-recovery discharge protocol was already in place, and the discharge process had been reviewed.

Verbatim wording from the response
“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 7 · response
Published 8 March 2018
Open published response
3 Jan2018
Surrey
Concerns raised2
1. Failure of hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information
2. Failure of discharge-planning procedures to pass occupational therapists’ recommendations for necessary support and equipment to community carers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Amend the discharge-letter template to consolidate medication information and instruct junior doctors to keep medication instructions in that section.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated planned
2. Action
  Pilot red bags and care passports with care providers, including updated information and earlier communication before and after hospital discharge.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progress
3. Action
  Add a discharge-summary section for therapists to provide community providers with instructions about equipment required after discharge.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated planned
AI-generated summary

Margaret Jean Silver · 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 Jean Silver, an 85-year-old resident of a care home, developed pulmonary emboli after Rivaroxaban was discontinued following contradictory medication instructions in her hospital discharge summary. She later experienced reduced mobility, sustained a fractured femur in an assisted fall, developed a chest infection, and died in hospital. Concerns included contradictory discharge medication information, failure to identify that Rivaroxaban had been discontinued, and failures in communicating and implementing recommended discharge support and equipment.

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 hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information
Wider context from the report
“- Current procedures may result in inaccurate or contradictory information about prescribed medication being included in hospital discharge summaries. ”
Source location
Margaret Jean Silver · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of discharge-planning procedures to pass occupational therapists’ recommendations for necessary support and equipment to community carers
Wider context from the report
“- The procedures in place for discharge planning may fail to ensure that occupational therapists’ recommendations regarding necessary support and equipment are not passed on to those caring for patients in the community. ”
Source location
Margaret Jean Silver · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Amend the discharge-letter template to consolidate medication information and instruct junior doctors to keep medication instructions in that section.

Verbatim wording from the response
“The Trusts discharge letter template is to be amended to enhance safety associated with the generation and consequently improve end-user clarity regarding medications. All information pertaining to medications will be included in the same section on the discharge letter. An instruction note to be added to inform the Junior Doctors that all medication instructions should be confined to the medication section on the letter.”

Source location
2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
Page 1 · response
Published 7 March 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Pilot red bags and care passports with care providers, including updated information and earlier communication before and after hospital discharge.

Verbatim wording from the response
“The Trust has commenced a pilot on the 12th February 2018 on new ways of working with nursing, residential and domiciliary care providers. Since March 2017 a multidisciplinary team of professionals from Ashford and St Peter’s NHS Foundation Trust and Adult Social Care have been working with a number of providers to identify better ways of working that will improve outcomes for individuals during and after their stay in hospital.”

Source location
2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
Page 2 · response
Published 7 March 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Add a discharge-summary section for therapists to provide community providers with instructions about equipment required after discharge.

Verbatim wording from the response
“The ‘Red Bag’ process described above will improve the multidisciplinary communication between providers. Additionally there will be a section added to the discharge summary letter whereby Therapists can provide community providers with appropriate instructions regarding equipment required following discharge.”

Source location
2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
Page 2 · response
Published 7 March 2018
Open published response
18 Dec2017
Inner South London
Concerns raised4
1. Failure of the HTT to obtain a written discharge plan from the hospital
2. Failure to liaise with the HTT before discharge
3. Failure to formulate a written discharge plan identifying the responsible community HTT
1. Failure to identify a responsible HTT for the discharge address
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review the transfer-of-care protocol to address obtaining missing information from referring or receiving services.
  Stated by Oxleas NHS Foundation TrustStated completed
2. Action
  Disseminate the reviewed transfer-of-care protocol through the clinical effectiveness governance process.
  Stated by Oxleas NHS Foundation TrustStated planned
3. Action
  Review and relaunch the discharge policy, strengthening family involvement, care-plan circulation, service identification and written acceptance of follow-up responsibility.
  Stated by Recipient name withheldStated completed
1. Action
  Deliver a rolling webinar training programme highlighting discharge-planning policy, family communication, care-plan circulation and follow-up service responsibilities.
  Stated by Recipient name withheldStated planned
Respondent positions 1
1. Position
  The fourth and fifth concerns relate to Oxleas Mental Health NHS Trust rather than Priory Group.
  Stated by Recipient name withheldRedirects responsibility
AI-generated summary

Anne Morris · 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

Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the HTT to obtain a written discharge plan from the hospital
Wider context from the report
“(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████). ”
Source location
Anne Morris · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to liaise with the HTT before discharge
Wider context from the report
“(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge. ”
Source location
Anne Morris · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to formulate a written discharge plan identifying the responsible community HTT
Wider context from the report
“(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues. ”
Source location
Anne Morris · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify a responsible HTT for the discharge address
Wider context from the report
“(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge. ”
Source location
Anne Morris · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the transfer-of-care protocol to address obtaining missing information from referring or receiving services.

Verbatim wording from the response
“• Our ‘Transfer of Care within Oxleas and externally’ protocol has been reviewed by the Medical Director, because it only described the information which should be provided to other units not what services should do in order to obtain information when a patient is referred / transferred. This will ensure standardisation in all Oxleas services in addition to the Home Treatment Team and this will then be disseminated through our clinical effectiveness governance process. This action is complete.”

Source location
2017-0383-Response-by-Oxleas-NHS-Trust_Redacted
Page 1 · response
Published 12 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Disseminate the reviewed transfer-of-care protocol through the clinical effectiveness governance process.

Verbatim wording from the response
“• Our ‘Transfer of Care within Oxleas and externally’ protocol has been reviewed by the Medical Director, because it only described the information which should be provided to other units not what services should do in order to obtain information when a patient is referred / transferred. This will ensure standardisation in all Oxleas services in addition to the Home Treatment Team and this will then be disseminated through our clinical effectiveness governance process. This action is complete.”

Source location
2017-0383-Response-by-Oxleas-NHS-Trust_Redacted
Page 1 · response
Published 12 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and relaunch the discharge policy, strengthening family involvement, care-plan circulation, service identification and written acceptance of follow-up responsibility.

Verbatim wording from the response
“Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

Source location
2017-0383-Response-by-Priory-Group
Page 1 · response
Published 12 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver a rolling webinar training programme highlighting discharge-planning policy, family communication, care-plan circulation and follow-up service responsibilities.

Verbatim wording from the response
“Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

Source location
2017-0383-Response-by-Priory-Group
Page 1 · response
Published 12 February 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The fourth and fifth concerns relate to Oxleas Mental Health NHS Trust rather than Priory Group.

Verbatim wording from the response
“We note that the fourth and fifth matters of concern relate to Oxleas Mental Health NHS Trust rather than to Priory Group.”

Source location
2017-0383-Response-by-Priory-Group
Page 2 · response
Published 12 February 2018
Open published response
12 Dec2017
Birmingham and Solihull
Concerns raised2
1. Inadequate discharge planning
2. Failure to arrange an outpatient appointment within 3 weeks of discharge
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
2. Action
  Create three daily hot-clinic slots to provide capacity for expedited post-discharge Trauma and Orthopaedic follow-up.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
AI-generated summary

Francis Robert Beech · 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

Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

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
Inadequate discharge planning
Wider context from the report
“2. Lack of continuity of care. Each week a different consultant took over his care. This led to a lack of continuity and inadequate discharge planning. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to arrange an outpatient appointment within 3 weeks of discharge
Wider context from the report
“4. Failing to arrange an outpatient appointment within 3 weeks of discharge. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.

Verbatim wording from the response
“Following the findings from this report, guidelines will be formulated for clinicians to follow for these patients. These will include recommended timescales for follow-up and x-ray reviews to be used in conjunction with clinical judgement. The new guidelines will be called ‘Conservative Management of Unstable Fractures’ and will be implemented by the Trust by 31 March 2018. Once the guideline has been implemented, the Directorate will audit compliance. If you would like to see the guidelines, please let me know.”

Source location
2017-0367-Responses
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Create three daily hot-clinic slots to provide capacity for expedited post-discharge Trauma and Orthopaedic follow-up.

Verbatim wording from the response
“The Trust has taken steps to reduce the time that a patient will now experience when awaiting an outpatient appointment for a consultant in Trauma & Orthopaedics. To support patients being seen in outpatient appointments expeditiously the Trust has created 3 daily “hot clinic” slots for post discharge follow-up. This will ensure that there is capacity to facilitate these reviews.”

Source location
2017-0367-Responses
Page 3 · response
Published 11 February 2018
Open published response
30 Nov2017
Black Country
Concerns raised1
1. Failure to communicate previous tramadol overdose information to the General Practitioner on the hospital discharge letter
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review standards for discharge communications.
  Stated by Dudley Integrated Health and Care NHS TrustStated planned
2. Action
  Reiterate to medical staff the importance of including necessary incidents and risk factors in discharge letters.
  Stated by Dudley Integrated Health and Care NHS TrustStated planned
3. Action
  Agree required audit frequency and standards for discharge communication, then communicate them to medical teams.
  Stated by Dudley Integrated Health and Care NHS TrustStated planned
AI-generated summary

Ms Penelope Benton · 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

Ms Penelope Benton, who had a history of paranoid schizophrenia, self-harm and significant pain, died on 12 July 2017 after taking a significant quantity of Tramadol. The principal concern was that her previous Tramadol overdose was not recorded in the hospital discharge letter and was therefore not communicated to her GP, who continued prescribing Tramadol.

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 communicate previous tramadol overdose information to the General Practitioner on the hospital discharge letter
Wider context from the report
“1. Evidence emerged during the inquest that the General Practitioner wasn’t made aware of the previous tramadol overdose on the discharge letter from Hospital. ”
Source location
Ms Penelope Benton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review standards for discharge communications.

Verbatim wording from the response
“As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharging communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.”

Source location
2017-0349-Response-by-Dudley-and-Walsall-NHS-Trust
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reiterate to medical staff the importance of including necessary incidents and risk factors in discharge letters.

Verbatim wording from the response
“As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharging communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.”

Source location
2017-0349-Response-by-Dudley-and-Walsall-NHS-Trust
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Agree required audit frequency and standards for discharge communication, then communicate them to medical teams.

Verbatim wording from the response
“It should also be noted that consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs to ensure / monitor the quality of discharge communication and ensure that the standard of these letters remains high. A required frequency / standard of audit and checking will be agreed as part of this review”

Source location
2017-0349-Response-by-Dudley-and-Walsall-NHS-Trust
Page 1 · response
Published 11 February 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to communicate with community GPs before discharge about ongoing melatonin prescribing

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to accurately transcribe significant individual results into discharge letters

Failure to include a complete set of blood results in discharge letters

Concerns raised2

Failure to prescribe safe quantities of discharge medication for patients at risk of stockpiling medication

Failure to record the quantities of discharge medication issued

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Discharge from hospital without follow-up

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

Concerns raised2

Failure to assign responsibility for chasing test results before discharge

Failure to chase outstanding test results before discharge

Concerns raised1

Lack of a coherent urology enhanced recovery discharge planning protocol

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Concerns raised2

Failure of hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information

Failure of discharge-planning procedures to pass occupational therapists’ recommendations for necessary support and equipment to community carers

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

Concerns raised4

Failure of the HTT to obtain a written discharge plan from the hospital

Failure to liaise with the HTT before discharge

Failure to formulate a written discharge plan identifying the responsible community HTT

Failure to identify a responsible HTT for the discharge address

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

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

Actions described in response 2

Actions described in response 1

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 3

Actions described in response 4

Respondent positions 1