12 Mar 2015 NICOLA ANNE TWEEDY · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to ensure the nurse completing discharge notes has seen the patient View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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NICOLA ANNE TWEEDY · 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
Mrs Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure the nurse completing discharge notes has seen the patient
Wider context from the report “There was no evidence that the Nurse completing the notes had actually seen Mrs Tweedy prior to discharge.
” Source location NICOLA ANNE TWEEDY · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge documentation concern was considered a misinterpretation because nursing evidence indicated the patient had been seen and relevant advice recorded.
Verbatim wording from the response “We believe that this issue must be based on a misinterpretation, as the evidence of the nurse completing the notes had actually seen the patient.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s implemented Action Plan was considered to have addressed the reported care concerns, with learning and improvement demonstrated.
Verbatim wording from the response “I note that you have sent your report to the Norfolk and Norwich University Hospital NHS Foundation Trust. My officials have liaised with the Foundation Trust about your report and I understand that it has fully considered and responded to each of your concerns relating to the care of Mrs Tweedy. I can report that a recent independent external inspection found that the Foundation Trust had implemented an Action Plan, to address the issues raised by this case, and that this demonstrated that learning and improvement had taken place.” Source location 2015-0095-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Professional regulatory bodies are responsible for investigating registrants’ alleged failures to meet standards and taking necessary safeguarding action.
Verbatim wording from the response “Lastly, as some of the actions of medical and nursing staff are subject to criticism in your report, I wish to take this opportunity to remind you of the role of the professional regulatory bodies and their fitness-to-practise processes.” Source location 2015-0095-Response-by-Department-of-Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department cannot become involved in or comment on individual cases.
Verbatim wording from the response “health and well-being of the public. The Department cannot get involved with or comment on individual cases.” Source location 2015-0095-Response-by-Department-of-Health
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Concerns raised 1
Inappropriate discharge care planning View source
This report raised 5 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.
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Henry Denis Whitwell Powell · 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
Henry Denis Whitwell Powell, who had advanced dementia and required 24-hour care, died on 11 August 2014 after a fall while climbing over bed rails, suffering a head injury and not regaining consciousness. The principal concerns were inappropriate discharge care planning, misunderstanding and insufficient training regarding bed rails, and inadequate coordination and follow-up between hospital and community services for equipment provision.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inappropriate discharge care planning
Wider context from the report “(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff.
” Source location Henry Denis Whitwell Powell · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide relevant staff with training on discharge processes and bed-rail risk assessment.
Verbatim wording from the response “adhering to the approved process for discharge including when bed rails are to be provided. Supported by our Acting Chief Nurse, she will ensure that training is provided to relevant staff on the Trust's processes for discharge and this will include training on bed rails risk assessment.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to forward bed-rail risk assessments and care plans to community carers, record the information on ICE transfer letters, and audit compliance.
Verbatim wording from the response “All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited. In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, to ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making, for the use of bed rails for patients who are at risk of slipping, sliding or rolling out of bed in the hospital setting.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify a joint bed-rail policy covering assessment, care planning, and handover between hospital and community services.
Verbatim wording from the response “On your second and third concerns I am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse is working collaboratively with representatives from community hospitals, community nursing and NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to the policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and agree a universal bedrail risk-assessment tool, standardised care plans and consistent transfer-of-care arrangements.
Verbatim wording from the response “Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails. Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed the areas for development and wider consideration. The draft combined policy will be available for each organisation to adopt by the end of April 2015.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide minimum bedrail information and define staff responsibilities for continuing risk assessment during patient transfers and discharge.
Verbatim wording from the response “The newly devised shared policy for the safe use of bedrails will include the responsibilities of staff when transferring patients, stating when and who will provide on-going risk assessments. For patients discharged from healthcare services with an on-going need for bed rail use with formal or informal carers a minimum standard of information will be provided. The local authorities have been involved to determine the most appropriate transfer of care arrangements for those patients who do not have a continued health care need.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
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4 Feb 2015 Paul Moroney · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to monitor oxygen saturations before discharge after oxygen therapy View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Paul Moroney · 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
Paul Moroney attended Tameside Hospital by ambulance on 27 August 2014 with worsening breathing and concern about a blood clot, was discharged with arrangements to return the following day, and later required a second emergency ambulance. Concerns included the lack of monitoring or recording of his oxygen saturations, discontinuation of oxygen before discharge without monitoring, and the absence of previous oxygen-level records when he was readmitted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to monitor oxygen saturations before discharge after oxygen therapy
Wider context from the report “2. Having been put on oxygen in the hospital, this was discontinued and he was sent home without his Oxygen saturations being monitored
” Source location Paul Moroney · Prevention of Future Deaths report
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19 Jan 2015 Simon Robert ALLISTON · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3
Discharge of patients despite ongoing assessed need for support View source Failure to provide a formal handover at discharge View source Failure to record the reason for discharge View source
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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Simon Robert ALLISTON · 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
Simon Robert ALLISTON lived alone and was found deceased in his flat after neighbours had not seen him for approximately a week; paramedics confirmed his death. The concerns included his discharge from mental health services without a formal handover, despite the Community Team considering that he still needed support, with no recorded reason for discharge and no formal Serious Incident Investigation after his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discharge of patients despite ongoing assessed need for support
Wider context from the report “(2) That he was discharged when the Community Team still considered that he needed support .
” Source location Simon Robert ALLISTON · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a formal handover at discharge
Wider context from the report “(1) That a patient with a long mental health history was discharged without a formal hand over .
” Source location Simon Robert ALLISTON · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record the reason for discharge
Wider context from the report “(3) That the reason for discharge was never recorded .
” Source location Simon Robert ALLISTON · Prevention of Future Deaths report
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15 Dec 2014 Andrew James AITKEN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to ensure patients have appropriate clothing and footwear at discharge View source
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.
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Andrew James AITKEN · 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
Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure patients have appropriate clothing and footwear at discharge
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes .
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint.
” Source location Andrew James AITKEN · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward had done everything possible regarding discharge without clothes or shoes, so the safeguarding alert was closed.
Verbatim wording from the response “The investigation involved communicating with ████████ who is the senior sister on ward 11C. She told me that she remembered this man very well. She stated that he was medically fit and the psychiatry team had discharged him; he was willing to go home and so they could not keep him in hospital. He did not have any clothes with him and he told staff that no one could bring him any in. The Trust booked and paid for a taxi to take him home as they did not want him going home on public transport in hospital pyjamas. The ward did receive a complaint in June whereby a safeguarding alert was raised, although it was deemed that the ward had done everything it could at the time and so the safeguarding was closed.” Source location 2014-0561-Response-by-Barts-Health-NHS-Trust
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5 Dec 2014 Elaine Marilyn GILES · Prevention of Future Deaths report South Lincolnshire
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Concerns raised 1
Lack of detailed assessment of likely functional performance in home circumstances after discharge View source
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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Elaine Marilyn GILES · 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
Elaine Marilyn GILES, a 66-year-old woman, died from fat embolism after falling while descending the stairs at home five days after discharge following hip replacement surgery. The principal concern was that she had been assessed as safe on stairs before discharge but could not safely negotiate the stairs at home, highlighting the need for detailed assessment of likely function in the home and adequate support after discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of detailed assessment of likely functional performance in home circumstances after discharge
Wider context from the report “Whilst assessed as "safe" on stairs prior to discharge from Peterborough City Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home. This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment.
” Source location Elaine Marilyn GILES · Prevention of Future Deaths report
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10 Nov 2014 Roseanne Cooke · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of the Recovery Team to attend discharge planning meetings View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Roseanne Cooke · 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
Roseanne Cooke experienced a marked deterioration in her mental health, including suicidal thoughts, and was found having taken her own life at her mother’s home on 1 May 2014. The report identified concerns about unavailable inpatient psychological input, confusion and delays regarding psychological-service referrals, the absence of the Recovery Team from a discharge-planning meeting, and inadequate communication of the family’s concerns about her safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the Recovery Team to attend discharge planning meetings
Wider context from the report “On the 17th April there was a meeting which ultimately led to the discharge of the deceased from hospital. The Care Co-Coordinator had already expressed that she would not be available due to annual leave but had left details of her colleague who would attend if this was a discharge planning meeting. No-one from the Recovery Team attended this meeting. They were the prime carers for the deceased on her discharge and had the role of Care Co-ordinator.
” Source location Roseanne Cooke · Prevention of Future Deaths report
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31 Oct 2014 CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report Inner South London
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Concerns raised 2
Failure to comprehensively plan discharge arrangements View source Failure to secure appropriate accommodation and care support at discharge View source
This report raised 5 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.
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CHRISTOPHER TOKE AJAYI · 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
Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to comprehensively plan discharge arrangements
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” Source location CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to secure appropriate accommodation and care support at discharge
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” Source location CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Debrief involved staff and remind Trust and local-authority staff about discharge planning, documentation and physical-health guidance.
Verbatim wording from the response “• All Trust and London Borough of Southwark (LBS) staff involved in this specific case gave evidence, learnt lessons and have been de-briefed on the Coroner’s conclusions.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement updated action plans producing more robust systems and structures between Southwark inpatient and community teams.
Verbatim wording from the response “• The breakdown in effective clinical communication and collaborative care planning was noted in the Trust’s SI investigation report (together with action plans) and further acknowledged and discussed in supporting evidence given at Inquest.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete discharge notification proformas routinely and send them to community teams or team managers on the discharge day, with ongoing audit.
Verbatim wording from the response “• Discharge proforma (discharge notification): this is now routinely completed and copies sent to community team/team manager on the day of discharge (compliance is monitored through ongoing audit).” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
Verbatim wording from the response “• The community team involved have undertaken two specific audits: (a) Team 7 day follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of two patients with unstable diabetes (Dec 2014) demonstrated extensive communication and forward planning prior to discharge, appropriately involving all partners.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review housing and community-support needs with partners for patients managing physical health independently in the community.
Verbatim wording from the response “• Partnership working around social care and support: discussions are currently underway reviewing housing and community support needs for patients to appropriately address physical health once living independently in the community” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There are no systemic problems with discharge and community follow-up for patients with complex mental and physical health needs.
Verbatim wording from the response “The Trust acknowledges that important lessons have been learnt from this specific case that are being taken forward in improving integrated working; the Trust is otherwise confident that there is no systemic problems with regard to discharge and community follow up of similar patients with complex mental and physical health problems.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
Open published response
3 Oct 2014 John Andrews · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Failure to ensure appropriate care is in place at home before discharge View source Failure to advise family members of discharge View source
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.
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AI-generated summary
John Andrews · 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 Andrews, who had a history of stroke and recurrent falls, was admitted after falls at home and later developed pneumonia and died on 1 June 2014. The principal concern was that he was discharged home without his family being advised, with no groceries or heating and without formal care arrangements in place; he fell while home alone before care was arranged.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure appropriate care is in place at home before discharge
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Mr Andrews was admitted to Milton Keynes Hospital on 31st March 2014 following a fall.
(2) Following detailed discussion with ████████ Mr Andrews was discharged from hospital.
(3) Mr Andrews was insistent that he wanted to be discharged.
(4) ████████ agreed reluctantly, but decided that a discharge would be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital.
(5) Upon discharge the plan agreed with ████████ was to implement a care package to assist Mr Andrews at home.
(6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance.
(7) Formal care arrangements were not arranged until 2-3 days later (Monday). It was too late, as Mr Andrews had fallen when home alone on the first day and was found on the floor by his son, who happened to phone his father, to be told he was at home.
(8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home to meet their needs.
” Source location John Andrews · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to advise family members of discharge
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Mr Andrews was admitted to Milton Keynes Hospital on 31st March 2014 following a fall.
(2) Following detailed discussion with ████████ Mr Andrews was discharged from hospital.
(3) Mr Andrews was insistent that he wanted to be discharged.
(4) ████████ agreed reluctantly, but decided that a discharge would be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital.
(5) Upon discharge the plan agreed with ████████ was to implement a care package to assist Mr Andrews at home.
(6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance.
(7) Formal care arrangements were not arranged until 2-3 days later (Monday). It was too late, as Mr Andrews had fallen when home alone on the first day and was found on the floor by his son, who happened to phone his father, to be told he was at home.
(8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home to meet their needs.
” Source location John Andrews · Prevention of Future Deaths report
Open source report
9 Sep 2014 Joyce Nelson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Unsafe discharge decisions despite significant injury View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Joyce Nelson · 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
Joyce Nelson fell at home on 7 March 2014 and fractured her pelvis in several places. The report raises concerns about delays in medical assessment, documentation and imaging results at the Emergency Department, and that she was to be discharged despite having a multi-fractured pelvis; it states that the delays were linked to reported shortages of emergency medicine doctors and radiologists.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe discharge decisions despite significant injury
Wider context from the report “3. Patient was to be discharged (even though it was later shown that she had a multi-fractured pelvis ).
” Source location Joyce Nelson · Prevention of Future Deaths report
Open source report
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Includes failures in hospital discharge planning, readiness decisions, multidisciplinary or receiving-service coordination, safety planning, execution and directly required follow-up.
