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.

30 Jan2014
Manchester South
Concerns raised4
1. Failure to consider the family’s views before discharge planning and implementation
2. Failure to hold the required pre-discharge meeting with the family
3. Lack of a pressure-relieving mattress at discharge home
1. Discharge home with severe pressure sores
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Develop a discharge checklist confirming MDT engagement with patients and families before discharge.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
2. Action
  Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
3. Action
  Provide patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStatus unclear
1. Action
  Formulate complex care plans for all parties to agree before patients return home.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStatus unclear
3. Action
  Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
AI-generated summary

Leslie Alfred Pates · 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

Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.

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 consider the family’s views before discharge planning and implementation
Wider context from the report
“2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”
Source location
Leslie Alfred Pates · 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 hold the required pre-discharge meeting with the family
Wider context from the report
“5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place. ”
Source location
Leslie Alfred Pates · 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 pressure-relieving mattress at discharge home
Wider context from the report
“2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”
Source location
Leslie Alfred Pates · 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
Discharge home with severe pressure sores
Wider context from the report
“2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. ”
Source location
Leslie Alfred Pates · 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
Develop a discharge checklist confirming MDT engagement with patients and families before discharge.

Verbatim wording from the response
“To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are being taken.”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 1 · response
Published 30 January 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
Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.

Verbatim wording from the response
“The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers.”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 2 · response
Published 30 January 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 patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.

Verbatim wording from the response
“To ensure the patients and families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken:”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 2 · response
Published 30 January 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
Formulate complex care plans for all parties to agree before patients return home.

Verbatim wording from the response
“A complex care plan has been formulated for all parties to agree the patient is supported and fully ready for home.”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 2 · response
Published 30 January 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
Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.

Verbatim wording from the response
“All plans of care for patients must be shared with the patient and, with patient’s consent, their next of kin and agreed before discharge.”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 2 · response
Published 30 January 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
Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.

Verbatim wording from the response
“All patients returning home with care package will have their equipment needs assessed and documented in hospital.”

Source location
2014-0043-Response-by-Tamside-Hospital-NHS
Page 2 · response
Published 30 January 2014
Open published response
23 Jan2014
Gwent
Concerns raised2
1. Failure to prescribe anti-coagulant medication on discharge
2. Failure to consider discharge home with anti-embolic stockings
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.
AI-generated summary

DESGRAE REGINA TUCKER · Prevention of Future Deaths report

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

Report summary

Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on 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 prescribe anti-coagulant medication on discharge
Wider context from the report
“(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed. (2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings. (3) No anti-coagulant medication prescribed to the patient upon discharge. ”
Source location
DESGRAE REGINA TUCKER · 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 consider discharge home with anti-embolic stockings
Wider context from the report
“(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed. (2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings. (3) No anti-coagulant medication prescribed to the patient upon discharge. ”
Source location
DESGRAE REGINA TUCKER · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Jan2014
Manchester South
Concerns raised1
1. Failure of discharge documentation to include vital admission and discharge information
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

John Joseph Malone · 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 Joseph Malone suffered two falls at home, the second on 24 October 2013, which led to a subdural haematoma; the inquest concluded that he died an accidental death. Concern was raised that the hospital discharge letter was woefully short on detail and omitted vital information for his GPs, and that he fell within three days of 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 of discharge documentation to include vital admission and discharge information
Wider context from the report
“I took evidence from the two GP's caring for the deceased and they showed to me, inter alia, a discharge letter from your hospital dated 21st October 2013 a copy of which I append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's. On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date. The patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage. ”
Source location
John Joseph Malone · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 Jan2014
Gateshead and South Tyneside
Concerns raised2
1. Failure of surgical teams to maintain ongoing oversight after discharge
2. Lack of a discharge plan for possible pelvic infection
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

Keith Fleming · 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

Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after 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 of surgical teams to maintain ongoing oversight after discharge
Wider context from the report
“Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears. On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future. ”
Source location
Keith Fleming · 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 discharge plan for possible pelvic infection
Wider context from the report
“Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears. On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future. ”
Source location
Keith Fleming · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Dec2013
South Yorkshire (Eastern)
Concerns raised1
1. Failure to notify Social Services of discharge contrary to their recommendations
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

ROSEMARY BRONWYN FERGUSON · 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

ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of 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 notify Social Services of discharge contrary to their recommendations
Wider context from the report
“(1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to them. ”
Source location
ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Dec2013
Manchester City
Concerns raised1
1. Failure to provide prison healthcare professionals with timely and complete discharge information
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

Horace Cottom · 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

Horace Cottom, a serving prisoner at HMP Manchester, died there on 21 June 2012 from pneumonia and heart disease with pseudomembranous colitis, with the inquest concluding that the death was from natural causes. The principal concern was that discharge information from NHS hospitals could take about 10 days to reach the prison and was sometimes incomplete, affecting the timely management of prisoners’ healthcare after hospital 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 provide prison healthcare professionals with timely and complete discharge information
Wider context from the report
“However, the inquest did establish that following his last discharge, it took about 10 days for any discharge information/report to be received at the prison from the NHS hospital. Further enquiries revealed that this was quite common and locally in Manchester the prison service tried to get the discharging doctor to write out in manuscript form discharge information. This is not always successful and results in delay, as well as incomplete discharge information. Recently, HMPS changed from using the NHS EMIS GP recording system and introduced what is known as 'System One'. This means that it is certainly easier for a prisoner who moves within the HMPS estate to have their GP records accessed immediately within the prison system. Locally in Manchester, they also try to use an email system to collect discharge information, but this is not without problems itself. From what I was told at the inquest, it seems that some NHS information can be transmitted directly onto the System One, but for some reason discharge information is not sent. HMPS caters for an increasing number of older prisoners with chronic health problems who have to attend outside NHS hospitals for investigations and treatment. It is vital that the healthcare professionals in prison have timely and full discharge information so that they can manage the care of the patient prisoner once they are returned to custody. One would hope that there is a simple and user-friendly way in which discharge information could be relayed to all prison healthcare establishments via the NHS. Whilst this has been highlighted as a local issue, I anticipate that it actually will be replicated nationwide. Accordingly, I am writing this letter under paragraph 37 & 38 of the enclosed Chief Coroner's Guidance No. 5 to bring this to your attention. I appreciate that it will involve a number of others who can assist in resolving the position and therefore I am also going to send a copy of this letter to the Chief Executive of the NHS, the Minister for Prisons, the Director General of HMPS, the Governor of HMP Manchester, as well as the Medical Directors of the major NHS Trusts in Greater Manchester. I sincerely hope a solution can be found. ”
Source location
Horace Cottom · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Oct2013
Liverpool
Concerns raised1
1. Failure to provide a discharge summary
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.
AI-generated summary

Rosa ANDERSON · 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

Rosa Anderson underwent laparoscopic repair of a diaphragmatic hernia, during which her oesophagus was inadvertently damaged. The resulting mediastinitis compromised her breathing and led to cardiac arrest and hypoxic brain injury; concerns included that she was discharged without a discharge summary, written information about the operation, advice contact numbers, or warnings about when to seek urgent medical assistance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide a discharge summary
Wider context from the report
“During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30th April 2013. Further, she was given no written information about her recent laparoscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance. ”
Source location
Rosa ANDERSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Oct2013
Cambridgeshire (South and West)
Concerns raised1
1. Delays in receiving and reviewing hospital discharge summaries
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

James Edward Mansfield · 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

James Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

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
Delays in receiving and reviewing hospital discharge summaries
Wider context from the report
“(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that the hospital post discharge letters to your surgery. This was not received until 28th February 2013 by which time Mrs Mansfield had called requesting stronger pain killers. The discharge summary was only reviewed by a doctor on 6 March. You stated that only if a patient was admitted to hospital would their discharge letter get prompt attention. There was no apparent method for differentiating between discharge summaries which involved serious injuries and those which did not. ”
Source location
James Edward Mansfield · Prevention of Future Deaths report
Page 1 · concerns
Open source report
24 Sep2013
County Durham and Darlington
Concerns raised1
1. Failure to notify family members of discharge where family support is relevant to safety
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

Linda Hudson · 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

Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after 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 notify family members of discharge where family support is relevant to safety
Wider context from the report
“(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided. ”
Source location
Linda Hudson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
17 Sep2013
Manchester South
Concerns raised1
1. Failure to make a discharge decision
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.
AI-generated summary

Alva JULLIEN · 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

Alva Jullien was admitted to hospital after a fall at home but remained there without a home assessment despite being considered medically fit for discharge. During her hospital stay she became recumbent and developed pneumonia; the inquest conclusion stated that missed opportunities during her care might have optimised her chances of survival. The principal concerns were communication and decision-making failures affecting discharge, and the decision to make her nil by mouth and place her on the Liverpool Care Pathway with, in the coroner’s view, insufficient evidence.

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 make a discharge decision
Wider context from the report
“There was clear evidence at the Inquest that ████████ daughter of the deceased, was not only able but willing to look after her mother in the home environment had her mother been discharged and it seemed clear to me from the evidence on a balance of probabilities that the deceased might well have survived had she have been discharged from hospital much earlier and that this discharge did not take place simply because of a lack of communication between the various health professionals and the want of a decision for discharge being taken. ”
Source location
Alva JULLIEN · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised4

Failure to consider the family’s views before discharge planning and implementation

Failure to hold the required pre-discharge meeting with the family

Lack of a pressure-relieving mattress at discharge home

Discharge home with severe pressure sores

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.6

Concerns raised2

Failure to prescribe anti-coagulant medication on discharge

Failure to consider discharge home with anti-embolic stockings

Concerns raised1

Failure of discharge documentation to include vital admission and discharge information

Concerns raised2

Failure of surgical teams to maintain ongoing oversight after discharge

Lack of a discharge plan for possible pelvic infection

Concerns raised1

Failure to notify Social Services of discharge contrary to their recommendations

Concerns raised1

Failure to provide prison healthcare professionals with timely and complete discharge information

Concerns raised1

Failure to provide a discharge summary

Concerns raised1

Delays in receiving and reviewing hospital discharge summaries

Concerns raised1

Failure to notify family members of discharge where family support is relevant to safety

Concerns raised1

Failure to make a discharge decision

Actions described in response 6