Recurring concern

Unreliable hospital discharge processes

First to latest report 30 Jan 2013 — 10 Jun 2026

Reports that mention this concern
273
Times this concern has been raised
406
Stated actions linked to this concern
524

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.

What is 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 and published responses 273 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Worcestershire

    AI-generated summary

    Timothy Thomas Reading · 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

    Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers

    Wider context from the report

    “(1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions. This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case. ”

    Source location

    Timothy Thomas Reading · 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

    Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.

    Verbatim wording from the response

    “The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care Board and local authority to provide aftercare services for individuals detained under certain sections of the Act following discharge.”

    Source location

    Response from Birmingham and Solihull MH NHS Foundation Trust
    Page 1 · response
    Published 23 February 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust is better placed to respond to concerns about the absence of a requested Section 117 plan.

    Verbatim wording from the response

    “We note that your report has also been addressed to the Trust who will be better placed to respond to the concerns raised around the absence of Section 117 plan provided by the Trust despite it being requested.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 February 2026

    Open published response

  2. Essex

    AI-generated summary

    Paolino AMICO · 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

    Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide clear oxygen-therapy discharge planning and referral information

    Wider context from the report

    “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”

    Source location

    Paolino AMICO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

    Verbatim wording from the response

    “The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 19 November 2025

    Open published response

  3. Kent and Medway

    AI-generated summary

    Ernest Roy Gray · 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

    Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to involve the patient’s cohabiting carer in discharge planning

    Wider context from the report

    “(1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer. ”

    Source location

    Ernest Roy Gray · Prevention of Future Deaths report
    Page 3 · 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

    Request and develop IT record changes to distinguish carers from next of kin.

    Verbatim wording from the response

    “1. We have requested IT record changes to correctly identify the carer(s) involved so they can be involved in appropriate discussions and decisions. Our current IT systems do not allow us to differentiate ‘carer’ from ‘next of kin’ (they can be different as was the case with Mr Gray). We recognise that this will be key in clearly identifying the carer for future discharge conversations so we have raised this urgently with the Sunrise team to investigate. The request has been made and is being prioritised.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    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

    Audit identification of carers and their support needs among patients aged 70 or over.

    Verbatim wording from the response

    “2. We carried out a snapshot audit in January 2026 of a sample of up to 50 patients aged 70 or over to specifically investigate how their carer is currently identified on our IT systems and from then, what support the carer may require to give assurances that the Carer’s Policy and Discharge Policy is being followed. Early findings as is frequently seen; is that families of confused patients are becoming exhausted and unable to cope. They are currently only identified as ‘NOK’, followed by their relationship (son, daughter) and not whether they are the carer. The planned addition of the NOK field will allow for easier audits and monitoring in the future.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.

    Verbatim wording from the response

    “3. We have allocated an experienced discharge advisor to a new Carer’s Champion post. This individual has been identified, and they commenced their role in early January. They will support the ward multi-disciplinary teams to identify the patient’s carer and ensure that the carer themselves is involved in the discharge discussions from early in the admission.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    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

    Re-audit progress on carer identification and support in February, March and April.

    Verbatim wording from the response

    “9. Mapping of Progress by re-audit by the Carers Champion will take place in February, March and April this year.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 4 · response
    Published 14 November 2025

    Open published response

  4. Shropshire, Telford and Wrekin

    AI-generated summary

    Lynn SILCOCK · 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

    Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.

    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 obtain cardiology review of discharge appropriateness

    Wider context from the report

    “(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate. ”

    Source location

    Lynn SILCOCK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.

    Verbatim wording from the response

    “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 19 December 2025

    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

    Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.

    Verbatim wording from the response

    “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 19 December 2025

    Open published response

  5. Essex

    AI-generated summary

    Jillian Anne Steedman · 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

    Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete discharge care plans, risk assessment and procedures

    Wider context from the report

    “(4) The mental health Trust staff involved in the discharge and community care of Mrs Steedman were put on notice by a clinical lead on 16 March 2023 that the care plans, risk assessment and procedures relevant to the discharge had not been completed and were required in addition to the integrated plan that was attached to the email. These were never completed. ”

    Source location

    Jillian Anne Steedman · 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

    Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.

    Verbatim wording from the response

    “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

    Source location

    Response from Essex Partnership University
    Page 1 · response
    Published 14 October 2025

    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

    Address the importance of recording information in care-plan sections through staff meetings, supervision and audit.

    Verbatim wording from the response

    “Response: Since Mrs Steedman’s death, the importance of recording information in the care-plan section has been addressed. This has included discussing in meetings with staff, supervision and audit.”

    Source location

    Response from Essex Partnership University
    Page 2 · response
    Published 14 October 2025

    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

    Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.

    Verbatim wording from the response

    “Response: We refer to our reply above under concern 4 in respect of care plans and risk assessments. In addition, as part of team reflections in this matter, the importance of professional curiosity was discussed and the team were reminded that they should review care home paperwork (where access is possible) and also speak with carers within the home. Support sessions were provided on asking right questions using professional curiosity and how this would have given more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the Care Home may in turn approach the Trust with regards to any information or support required.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    Open published response

  6. Manchester South

    AI-generated summary

    Amanda Wood · 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

    Amanda Wood died on 3 January 2025 at Tameside General Hospital as a consequence of sepsis related to a long-term gastrostomy and Crohn’s disease. The principal concern was that there was no evidence of a sepsis screen being undertaken before her discharge from the Emergency Department on 28 December 2024, after which she was readmitted within 24 hours.

    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 undertake a sepsis screen before Emergency Department discharge

    Wider context from the report

    “Notwithstanding the ongoing work reported by the Trust in respect of the early identification and treatment of sepsis, I am concerned that there is no evidence of any sepsis screen being undertaken prior to Miss Wood’s discharge from the Emergency Department on 28th December 2024. ”

    Source location

    Amanda Wood · Prevention of Future Deaths report
    Page 2 · 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

    Existing triage, NEWS assessment and consultant review are considered sufficient; sepsis screening need not be repeated before Emergency Department discharge.

    Verbatim wording from the response

    “Firstly, it is important to note that when patients present to the Emergency Department they are triaged in line with the Manchester Triage System, which is a clinical risk management tool used by clinicians worldwide to enable them to safely manage patient flow when clinical need far exceeds capacity. The triage system categorises patients in order of priority and all patients attending the ED should be triaged, or initially assessed, within 15 minutes. As part of this triage, observations are taken using the National Early Warning Score (NEWS) which is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. Mrs.”

    Source location

    Response from Tameside and Glossop Integrated Care NHS Foundation Trust
    Page 1 · response
    Published 9 October 2025

    Open published response

  7. North Yorkshire and York

    AI-generated summary

    Pamela Ann HONEYBONE · 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

    Pamela Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification processes.

    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 check CT scan outcomes before patient discharge

    Wider context from the report

    “1. It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient's CT scan prior to her discharge a few hours later. ”

    Source location

    Pamela Ann HONEYBONE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Worcestershire

    AI-generated summary

    John Franklin · 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

    John Franklin, who lived alone and was at high risk of falls, suffered a fall after discharge home, followed by dehydration, reduced mobility, contractures and pressure ulcers. He deteriorated despite treatment and died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. The principal concern was that he was discharged home before a careline/lifeline pendant was provided, although the records later indicated that one was installed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls

    Wider context from the report

    “Mr Franklin lived alone and was assessed to be at high risk of falls. When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided. At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024. ”

    Source location

    John Franklin · Prevention of Future Deaths report
    Page 3 · 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 hospital discharge policy and procedures to ensure assistive technology needs and safe discharge decisions are explicit.

    Verbatim wording from the response

    “To ensure any learning is taken, we have reviewed our policy and procedures for hospital discharge. We are confident that the approach of ensuring AT needs are considered and only safe discharges are agreed is explicit in our process.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    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

    Consider assistive technology needs and associated risks before every hospital discharge.

    Verbatim wording from the response

    “Prior to hospital discharges we will always consider if there is a need for Assistive Technology (AT) to be in place for a safe discharge. There are occasions where AT is identified as beneficial but not essential and would not be deemed as necessary for safe hospital discharge, for instance where a person has other support means or is safe between calls and has the ability to understand the need to wait between calls and will not mobilise if there is a high risk of falls. Prior to hospital discharge, a triage process is undertaken to identify presenting needs and any risks, which would consider if AT is required to meet essential needs prior to discharge.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind staff to identify risks requiring mitigation through assistive technology before discharge.

    Verbatim wording from the response

    “Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge. Where this is deemed necessary for a safe discharge this will be shared with our acute colleagues and the person/representative and will be arranged in advance.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share necessary assistive technology requirements with acute colleagues and the person or representative, and arrange provision before discharge.

    Verbatim wording from the response

    “Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge. Where this is deemed necessary for a safe discharge this will be shared with our acute colleagues and the person/representative and will be arranged in advance.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    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 discharge triage process sufficiently identifies when assistive technology is essential for safe discharge, so it need not always be provided beforehand.

    Verbatim wording from the response

    “Prior to hospital discharges we will always consider if there is a need for Assistive Technology (AT) to be in place for a safe discharge. There are occasions where AT is identified as beneficial but not essential and would not be deemed as necessary for safe hospital discharge, for instance where a person has other support means or is safe between calls and has the ability to understand the need to wait between calls and will not mobilise if there is a high risk of falls. Prior to hospital discharge, a triage process is undertaken to identify presenting needs and any risks, which would consider if AT is required to meet essential needs prior to discharge.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    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

    Always providing assistive technology before discharge is not feasible because it would significantly delay discharges where it is not essential.

    Verbatim wording from the response

    “We would not be able to commit to AT always being in place prior to discharge as you can appreciate this would delay a significant number of discharges when the need has not been deemed essential.”

    Source location

    2026-0110 - Response from Worcestershire County Council
    Page 1 · response
    Published 2 March 2026

    Open published response

  9. Worcestershire

    AI-generated summary

    John Franklin · 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

    John Franklin, who was frail and at high risk of falls after hip surgery and prolonged hospitalisation, was found on the floor at home after a long lie and subsequently developed pressure ulcers and a deteriorating hip wound. He died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. A substantive concern was that he was discharged home before a careline/lifeline pendant was provided, with uncertainty about whether it had been installed when he was found on the floor.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls

    Wider context from the report

    “Mr Franklin lived alone and was assessed to be at high risk of falls. When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided. At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024. ”

    Source location

    John Franklin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. South Yorkshire (Eastern)

    AI-generated summary

    Walter Colin HORTON · 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

    Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.

    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 maintain adequate discharge handover information

    Wider context from the report

    “(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

    Source location

    Walter Colin HORTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.

    Verbatim wording from the response

    “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.

    Verbatim wording from the response

    “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

    Source location

    Response from Doncaster & Bassetlaw NHS Foundation Trust
    Page 2 · response
    Published 19 September 2025

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026