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.

4 Sep2014
Leicester City and South Leicestershire
Concerns raised2
1. Failure to properly assess fitness for discharge
2. Failure to properly plan discharge
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.
AI-generated summary

Gillian Crossley · 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

Gillian Crossley underwent elective bowel surgery, was discharged home, re-admitted the following day in extremis with bowel necrosis and perforation, and died on 28 March 2013 despite further surgery. The concerns included inadequate documentation, inadequate observation and monitoring, failure to properly assess and plan her discharge, and inadequate communication between those responsible for her care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to properly assess fitness for discharge
Wider context from the report
“I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry: (1) Inadequate documentation (2) Failure to observe and monitor in accordance with Mrs Crossley's needs (3) Failure to properly assess the fitness for discharge and properly plan that discharge (4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley ”
Source location
Gillian Crossley · Prevention of Future Deaths report
Page 1 · 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 properly plan discharge
Wider context from the report
“I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry: (1) Inadequate documentation (2) Failure to observe and monitor in accordance with Mrs Crossley's needs (3) Failure to properly assess the fitness for discharge and properly plan that discharge (4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley ”
Source location
Gillian Crossley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
29 Aug2014
Inner North London
Concerns raised2
1. Failure to complete physiotherapy assessment before discharge
2. Premature issuing of discharge paperwork
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.
Actions described in response 1
1. Action
  Remind nurses to provide discharge letters only after the discharge process is complete and update patient information sheets accordingly.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Irshad ALI · 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

Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

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 physiotherapy assessment before discharge
Wider context from the report
“4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place. The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family. The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go. Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete. ”
Source location
Irshad ALI · 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
Premature issuing of discharge paperwork
Wider context from the report
“4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place. The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family. The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go. Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete. ”
Source location
Irshad ALI · 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
Remind nurses to provide discharge letters only after the discharge process is complete and update patient information sheets accordingly.

Verbatim wording from the response
“It is Trust policy that the copy of the patients’ discharge letter should be given once all facets of the discharge process are complete. Nurses have been reminded of the policy and the requirement to update the patient information sheet with the information that the discharge summary should be given to the patient alongside their discharge medications. To facilitate this, the Trust continues to cultivate a continued effective relationship with the Trust discharge lounge.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
Open published response
6 Aug2014
Shropshire, Telford and Wrekin
Concerns raised2
1. Failure to send discharge summaries to patients’ GPs
2. Failure to provide prescribed medication at hospital discharge
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.

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

Martin Rowland HILL · 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

Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to send discharge summaries to patients’ GPs
Wider context from the report
“(6) For completeness, and it is an issue which arose in an earlier Inquest, no discharge summary was sent to the patient’s GP. This appears to have been an exception to normal practice and an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought. ”
Source location
Martin Rowland HILL · Prevention of Future Deaths report
Page 1 · 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 provide prescribed medication at hospital discharge
Wider context from the report
“(5) An additional concern arose separate to this. Mr Hill, when he was discharged on the 20th April, had been prescribed medication. Mr Hill should have left the hospital with that medication but none was provided to him. It is unlikely that its absence had any material effect in this case but it could in others. ”
Source location
Martin Rowland HILL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Aug2014
Norfolk
Concerns raised1
1. Inaccurate information in NNUH discharge letters
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 5
1. Action
  Revise the discharge letter template to simplify completion and emphasise critical information.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progress
2. Action
  Create a bespoke discharge letter template for Older People’s Medicine patients with relevant clinical fields.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progress
3. Action
  Revise clinician prompts for completing discharge letters to ensure inclusion of relevant information.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progress
1. Action
  Change the training programme supporting use of discharge letter templates.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progress
2. Action
  Monitor the changes’ effects and assess whether further steps are needed to support safe transfer between hospital and community.
  Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progress
AI-generated summary

JOHN HENRY WILSHER · Prevention of Future Deaths report

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

Report summary

Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.

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
Inaccurate information in NNUH discharge letters
Wider context from the report
“(1) The information contained in the NNUH Discharge Letter is inaccurate; ”
Source location
JOHN HENRY WILSHER · 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
Revise the discharge letter template to simplify completion and emphasise critical information.

Verbatim wording from the response
“The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:”

Source location
2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Page 1 · response
Published 5 August 2014
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 a bespoke discharge letter template for Older People’s Medicine patients with relevant clinical fields.

Verbatim wording from the response
“The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:”

Source location
2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Page 1 · response
Published 5 August 2014
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
Revise clinician prompts for completing discharge letters to ensure inclusion of relevant information.

Verbatim wording from the response
“The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:”

Source location
2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Page 1 · response
Published 5 August 2014
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
Change the training programme supporting use of discharge letter templates.

Verbatim wording from the response
“The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:”

Source location
2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Page 1 · response
Published 5 August 2014
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
Monitor the changes’ effects and assess whether further steps are needed to support safe transfer between hospital and community.

Verbatim wording from the response
“We will continue to monitor the effect of the changes outlined above and whether any further steps are necessary to promote the safe transfer of care between hospital and community.”

Source location
2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Page 1 · response
Published 5 August 2014
Open published response
30 Jun2014
Cumbria (North & West)
Concerns raised1
1. Failure to inform the GP of hospital discharge
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 1
1. Action
  Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

William Reid · 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

William Reid was found deceased at his home on 24 July 2013, having lived alone and with a delay in the discovery of his death. Concerns included delayed recognition of his deteriorating condition, delayed hospital admission, and failure to inform his GP about his hospital admission and discharge.

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 inform the GP of hospital discharge
Wider context from the report
“His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken. ”
Source location
William Reid · Prevention of Future Deaths report
Page 1 · 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
Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.

Verbatim wording from the response
“In addition, the Governments Information Strategy “The Power of Information: Putting all of us in control of the health and care information we need” was published in May 2012. A copy can be found on the GOV.UK website via the following link: The Power of Information. The Strategy sets a ten-year framework for transforming information for health and care. It aims to harness information and new technologies to achieve higher quality care and improve outcomes for patients and service users.”

Source location
2014-0288-Response-by-Department-of-Health
Page 2 · response
Published 30 June 2014
Open published response
9 Jun2014
Derby and Derbyshire
Concerns raised3
1. Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care
2. Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home
3. Failure to undertake post-discharge planning and assessment of follow-up care needs
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
  Complete the multidisciplinary review and finalise a clear policy for assessing elderly patients presenting after a fall.
  Stated by Chesterfield Royal Hospital NHS Foundation TrustStated in progress
2. Action
  Provide the ratified policy to the coroner.
  Stated by Chesterfield Royal Hospital NHS Foundation TrustStated planned
AI-generated summary

William Leonard Beckwith · 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

William Leonard Beckwith sustained a cervical spine fracture after a fall at home, was discharged from hospital without the fracture being diagnosed, and died on 11 October 2013 after readmission with acute stridor and subsequent deterioration. The principal concern was that, despite his age and history of falls, he was discharged home in the early hours without formal assessment of his abilities, his home environment, or his wife’s ability to care for him, and without post-discharge planning or needs assessment.

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 formal assessment of the patient’s abilities, home environment and carer’s ability to provide care
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
Source location
William Leonard Beckwith · 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
Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
Source location
William Leonard Beckwith · 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 undertake post-discharge planning and assessment of follow-up care needs
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
Source location
William Leonard Beckwith · 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
Complete the multidisciplinary review and finalise a clear policy for assessing elderly patients presenting after a fall.

Verbatim wording from the response
“However, in light of your letter a multidisciplinary review of this document is currently in progress with input from senior nursing staff, and care of the elderly physicians within the Medicine & Emergency Care Division. The result of this review will be a clear policy for staff to follow which I expect to be finalised by the end of August. Once the policy has been ratified, I will provide you with a copy for your information.”

Source location
2014-0258-Response
Page 1 · response
Published 9 June 2014
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
Provide the ratified policy to the coroner.

Verbatim wording from the response
“However, in light of your letter a multidisciplinary review of this document is currently in progress with input from senior nursing staff, and care of the elderly physicians within the Medicine & Emergency Care Division. The result of this review will be a clear policy for staff to follow which I expect to be finalised by the end of August. Once the policy has been ratified, I will provide you with a copy for your information.”

Source location
2014-0258-Response
Page 1 · response
Published 9 June 2014
Open published response
15 May2014
Manchester South
Concerns raised1
1. Discharge before completion of full investigations
This report raised 11 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 was considered appropriate because pain was controlled, there was no sepsis or obstruction, and a management plan existed.
  Stated by Stockport NHS Foundation TrustDisputes the concern
AI-generated summary

Gary Bradshaw · Prevention of Future Deaths report

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

Report summary

Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

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 before completion of full investigations
Wider context from the report
“5. The patient was discharged from the hospital on the 27th June 2012 rather than being retained as an in-patient whilst full investigations were carried out; again a practice which the expert witness felt to be inappropriate (Stockport NHS Trust) ”
Source location
Gary Bradshaw · 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 was considered appropriate because pain was controlled, there was no sepsis or obstruction, and a management plan existed.

Verbatim wording from the response
“5. Mr Bradshaw was discharged from the hospital on the 27th June rather than being retained as an inpatient whilst full investigations were carried out; again a practice which the expert witness felt to be inappropriate. Mr Bradshaw presented to the ED with renal colic and worsening of his kidney function; therefore the plan for that emergency admission was to control his pain and rule out urinary tract obstruction secondary to the known kidney stones as a cause of worsening of his kidney function. Mr Bradshaw had an urgent US scan of the urinary tract on the 26/6 and this showed previously known kidney stones with no evidence of hydronephrosis. The renal colic was controlled and Mr Bradshaw became symptomatically better; a management plan for the kidney stones had been made.”

Source location
2014-0232-Response-2
Page 2 · response
Published 15 May 2014
Open published response
3 Apr2014
Brighton and Hove
Concerns raised4
1. Failure to communicate discharge information to receiving care providers and family
2. Failure to ensure patients are medically fit for discharge
3. Failure to complete discharge paperwork
1. Failure to maintain an ongoing discharge process
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
1. Action
  Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
2. Action
  Increase junior nurses’ shadowing of senior colleagues to strengthen discharge decision-making and communication skills.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
3. Action
  Start and evaluate a one-year multidisciplinary pilot for consistent management of frail elderly patients across three wards, with learning intended for wider Trust implementation.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
4. Action
  Review the forms used for discharge planning.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
5. Action
  Add a social worker to the ward’s daily multidisciplinary Board Round to support discharge planning.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
6. Action
  Adjust Board Round whiteboard information to include discharge-planning details.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
1. Position
  The patient was medically ready for discharge, with satisfactory observations and no reason to regard him as medically unready.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
AI-generated summary

Graham Harold WATTS · 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

Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.

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 discharge information to receiving care providers and family
Wider context from the report
“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”
Source location
Graham Harold WATTS · 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 ensure patients are medically fit for discharge
Wider context from the report
“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”
Source location
Graham Harold WATTS · 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 complete discharge paperwork
Wider context from the report
“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”
Source location
Graham Harold WATTS · 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 maintain an ongoing discharge process
Wider context from the report
“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”
Source location
Graham Harold WATTS · 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
Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.

Verbatim wording from the response
“The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014
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
Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.

Verbatim wording from the response
“The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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
Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.

Verbatim wording from the response
“Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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
Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.

Verbatim wording from the response
“The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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
Increase junior nurses’ shadowing of senior colleagues to strengthen discharge decision-making and communication skills.

Verbatim wording from the response
“The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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
Start and evaluate a one-year multidisciplinary pilot for consistent management of frail elderly patients across three wards, with learning intended for wider Trust implementation.

Verbatim wording from the response
“The Trust is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, led by an individual from the discipline most relevant to the individual patient’s circumstances, in preparation for their discharge. Subject to successful recruitment, it is anticipated that the pilot will start in July 2014 on three wards. This pilot will be evaluated throughout the year as well as at its conclusion so that the learning from it can be extended throughout the Trust for the benefit of frail elderly patients.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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 forms used for discharge planning.

Verbatim wording from the response
“The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
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 social worker to the ward’s daily multidisciplinary Board Round to support discharge planning.

Verbatim wording from the response
“In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014
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
Adjust Board Round whiteboard information to include discharge-planning details.

Verbatim wording from the response
“In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014
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 process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.

Verbatim wording from the response
“The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014
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 patient was medically ready for discharge, with satisfactory observations and no reason to regard him as medically unready.

Verbatim wording from the response
“There is increasing recognition among Trust staff that the nationally widely used term “Medically Fit for Discharge” (often abbreviated to MFFD) can be very misleading. There is a growing ground-swell of opinion that it would be less open to misinterpretation if the phrase “Medically Ready for Discharge” (MRFD) or some similar form of words were adopted. Mr Watts was already for discharge in as much as that he no longer required active medical treatment in an acute hospital at the time of his discharge. His last set of clinical observations taken during the afternoon immediately before he left the hospital were entirely satisfactory, with a National Early Warning Score of zero: there was therefore no reason to identify him as medically unready for discharge.”

Source location
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014
Open published response
2 Apr2014
Black Country
Concerns raised1
1. Failure to medically reassess the patient before discharge
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.
AI-generated summary

Mr John Dodd · Prevention of Future Deaths report

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

Report summary

Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

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 medically reassess the patient before discharge
Wider context from the report
“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”
Source location
Mr John Dodd · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Mar2014
Staffordshire South
Concerns raised1
1. Failure to ensure clear and consistent discharge instructions
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

Norma Doris Sheppard · Prevention of Future Deaths report

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

Report summary

Norma Doris Sheppard fell in her care home, broke her right hip, underwent surgical repair, later suffered a stroke affecting her swallowing, and died on 10 April 2013 from the effects of the fall. There was considerable confusion about whether she was to receive subcutaneous fluids after discharge from hospital to a care home, contrary to the written discharge document.

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 ensure clear and consistent discharge instructions
Wider context from the report
“There was considerable confusion about the terms of Mrs Sheppard’s discharge from Queens Hospital to the care home on 25 March 2013. There was a written discharge letter that indicated that Mrs Sheppard should continue to receive sub cutaneous fluids at the care home and this presented considerable difficulties in finding somewhere suitable to take her. In fact when she was discharged it appears to be on an understanding that she was not going to receive sub cutaneous fluids although this was contrary to the discharge document. ”
Source location
Norma Doris Sheppard · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to properly assess fitness for discharge

Failure to properly plan discharge

Concerns raised2

Failure to complete physiotherapy assessment before discharge

Premature issuing of discharge paperwork

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 raised2

Failure to send discharge summaries to patients’ GPs

Failure to provide prescribed medication at hospital discharge

Concerns raised1

Inaccurate information in NNUH discharge letters

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.5

Concerns raised1

Failure to inform the GP of hospital discharge

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 raised3

Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care

Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home

Failure to undertake post-discharge planning and assessment of follow-up care needs

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 raised1

Discharge before completion of full investigations

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

Concerns raised4

Failure to communicate discharge information to receiving care providers and family

Failure to ensure patients are medically fit for discharge

Failure to complete discharge paperwork

Failure to maintain an ongoing discharge process

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.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Actions described in response 5

Actions described in response 1

Actions described in response 2

Respondent positions 1

Actions described in response 9

Respondent positions 2