29 Jan 2025 Naomi SULEYMAN · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3
Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs View source Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge View source Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Lewisham and Greenwich NHS Trust London Borough of Lewisham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
View source
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Develop standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
View source
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Progress the Occupational Therapy Policy through Trust governance approval.
View source
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
View source
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Conduct further multi-agency discharge events to improve communication and joint working.
View source See 2 more actions
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AI-generated summary
Naomi SULEYMAN · 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
Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.
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× 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 accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs
Wider context from the report “(1) The ‘discharge passport’ completed by the UHL in-patient team was inaccurate , failing to record Ms Suleyman’s vulnerability to pressure ulcers, the need for therapies input from day 1, the equipment she required and that her home environment had not been optimised to meet her needs both in terms of equipment and layout . Whilst I heard that scrutiny of the discharge passport had improved at ward level, deficient discharge passports were still filtering through to the D2A team .
” Source location Naomi SULEYMAN · 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 provide social work and/or occupational therapy assessment within 24 hours of discharge
Wider context from the report “(4) Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement team.
” Source location Naomi SULEYMAN · 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 conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process
Wider context from the report “The issues relating to LBL only emerged in evidence during the inquest. LGT in-patient and District Nursing services have taken some steps towards addressing their deficiencies. However, there has been a fragmented and incomplete response . There has been no overarching coordinated investigation involving all the key services relevant to what is intended to be an integrated multi-disciplinary discharge process .
” Source location Naomi SULEYMAN · 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 Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
Verbatim wording from the response “• Each member of the ward-based team, who is involved in the patient care, now provides input into the centrally located (and saved) discharge passports.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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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 standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
Verbatim wording from the response “• A multidisciplinary task and finish group has commenced work to outline standards of practice, and to define roles and responsibilities relating to prescription of pressure care equipment and hospital beds. The project will be undertaken using Quality improvement methodology and will produce guidance materials and teaching for staff by end of April 2025.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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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 Progress the Occupational Therapy Policy through Trust governance approval.
Verbatim wording from the response “• An Occupational Therapy Policy has been developed which outlines roles, responsibilities and processes relating to therapy practice for environmental assessments and equipment provision. This is currently being agreed through the Trusts governance procedures.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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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 Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
Verbatim wording from the response “• The discharge team now perform additional checks on the patient electronic care record to ensure there have been no last-minute changes in the patient's condition or discharge support needs. This is underpinned by a new protocol which has been shared with the team and operationally embedded into working practices.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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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 Conduct further multi-agency discharge events to improve communication and joint working.
Verbatim wording from the response “• A multi-agency discharge event was carried out on 05/03/2025 which tests the systematic approach to discharge processes and further events are planned to improve multi agency communication and ways of working.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
Open published response
17 Jan 2025 Jackson Yeow · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Delays in discharging medically fit patients for non-medical reasons View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Cwm Taf Morgannwg University Local Health Board
Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.
View source
Cwm Taf Morgannwg University Local Health Board
Continue the STAMP acute-medicine transformation programme to improve hospital flow and support discharge planning across the organisation.
View source
Cwm Taf Morgannwg University Local Health Board
Implement the Discharge to Recover then Assess model to move patients no longer requiring acute care into appropriate settings promptly.
View source
Cwm Taf Morgannwg University Local Health Board
Develop and operate a centralised Discharge Hub for patient flow and community bed allocation.
View source
Cwm Taf Morgannwg University Local Health Board
Continue collaboration with local-authority partners to improve social-care availability and reduce delayed discharges.
View source See 2 more actions
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AI-generated summary
Jackson Yeow · 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
Jackson Yeow, aged 16, became seriously unwell with abdominal pain and vomiting and later developed diabetic ketoacidosis and other complications. He waited approximately 9½ hours for an ambulance after his family called 999, and died on 9 April 2022. Concerns included delays in ambulance handovers associated with emergency department overcrowding, corridor care, and delayed discharge of medically fit patients.
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× 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 discharging medically fit patients for non-medical reasons
Wider context from the report “Although the Cwm Taf Morgannwg University Health Board did not provide direct care to Jackson Yeow during the period within scope, it provided the evidence of a consultant in emergency medicine to the inquest on the issue of delays in ambulance handovers at the Princess of Wales Hospital, Bridgend. That evidence directly identified the following matters of concern:
(1) Care for patients in the emergency department is frequently provided in the corridor and other non clinical spaces, which:
(a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult;
(b) Impedes the ability of staff to recognize a patient’s deteriorating condition;
(c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene and nutrition.
(d) May slow the process of ambulance handovers.
(2) Care in corridors and other non clinical spaces has been normalized, which in the opinion of the consultant who gave evidence is unsafe.
(3) When conducted routinely, care in corridors and other non clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances.
(4) The underlying obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non medical reasons .
” Source location Jackson Yeow · 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 Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.
Verbatim wording from the response “Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Continue the STAMP acute-medicine transformation programme to improve hospital flow and support discharge planning across the organisation.
Verbatim wording from the response “Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Implement the Discharge to Recover then Assess model to move patients no longer requiring acute care into appropriate settings promptly.
Verbatim wording from the response “- Ongoing work with Welsh Ambulance Service Trust (WAST) on optimum clinical patient pathways and the Discharge to Recover then Assess (D2RA) Hub, which has improved discharge planning and increased hospital capacity to accept new admissions.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
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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 Develop and operate a centralised Discharge Hub for patient flow and community bed allocation.
Verbatim wording from the response “To tackle delayed discharges, CTMUHB has implemented:
- The Discharge to Recover then Assess (D2RA) model, ensuring that patients who no longer require acute care are moved to the most appropriate setting as quickly as possible.
- We have also developed the Discharge Hub as a centralised resource for patient flow and community bed allocation.
- The Safe2Start meeting is now embedded pan CTM where twice a day the site is reviewed as a whole with real time demand and capacity being reviewed. Here clinical priorities are discussed and decisions are made in relation to patient flow, on boarding and balancing risk to ensure each area is safe to start.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Continue collaboration with local-authority partners to improve social-care availability and reduce delayed discharges.
Verbatim wording from the response “We continue to work in collaboration with local authority partners to improve social care availability and prevent unnecessary delays.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
17 Dec 2024 MARY MARGARET WHITLOCK · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to provide discharge summaries to care homes View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mid and South Essex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Mid and South Essex NHS Foundation Trust
Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.
View source
Mid and South Essex NHS Foundation Trust
Remind nursing staff to verify discharge-summary completion before patients leave the department.
View source
Mid and South Essex NHS Foundation Trust
Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.
View source
Mid and South Essex NHS Foundation Trust
Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.
View source See 1 more action
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AI-generated summary
MARY MARGARET WHITLOCK · 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
Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.
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× 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 discharge summaries to care homes
Wider context from the report “(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury
” Source location MARY MARGARET WHITLOCK · 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 Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.
Verbatim wording from the response “Following Mrs Whitlock’s experience, all our Emergency Medicine clinicians have been reminded of the requirement to complete a discharge summary to all patients in every case. We have highlighted the importance of these being available to patients who are not being discharged to their own home.” Source location Response from Mid & South Essex 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 Remind nursing staff to verify discharge-summary completion before patients leave the department.
Verbatim wording from the response “Nursing colleagues have also been reminded to check that this has been completed prior to the patient leaving the department upon discharge.” Source location Response from Mid & South Essex NHS Trust
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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 Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.
Verbatim wording from the response “We have included the learning from Mrs Whitlock’s case within our all-staff patient safety bulletin for January 2025 emphasising the importance of a full and accurate discharge summary being completed at the point of discharge.” Source location Response from Mid & South Essex 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 Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.
Verbatim wording from the response “We plan to monitor our performance with issuing discharge summaries within our 2025 trust-wide corporate audit programme to assure ourselves with compliance and use the results to take action as appropriate.” Source location Response from Mid & South Essex NHS Trust
Open published response
2 Dec 2024 Junior George Powell · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Lack of suitable community social care delaying discharge of patients ready to leave hospital View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Junior George 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
Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of 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 Lack of suitable community social care delaying discharge of patients ready to leave hospital
Wider context from the report “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such patients.
” Source location Junior George Powell · Prevention of Future Deaths report
Open source report
24 Sep 2024 George Neville Coulthard · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in identifying suitable care home placements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
George Neville Coulthard · 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
George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.
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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 Delays in identifying suitable care home placements
Wider context from the report “1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home . This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting.
In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period.
” Source location George Neville Coulthard · 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 Continue reviewing discharge processes, alternatives to hospital admission, and patient-flow pathways across Greater Manchester hospitals.
Verbatim wording from the response “You refer to such delays occurring on a regular basis and often exacerbated by the festive period. The winter period generally is extremely busy with high numbers of patients entering the hospital and needing to be admitted for care and treatment. Whilst every effort is made to appropriately manage the flow of patients to free up beds, there are occasions when delays in discharge do impact on patient flow. This is regrettably not a scenario that is specific to the festive period as such challenges occur throughout the year, but particularly through the winter months. As a system we consistently review discharge processes, alternatives to hospital admission, and patient flow pathways. This is with a view to improving the patient experience and flow through all GM hospitals so that patients can receive the right care at the right time and in the right place.” Source location Response from GMIC
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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 Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.
Verbatim wording from the response “As part of our processes, we are currently conducting a further assessment (under our new Single Assessment Framework) to review all the shortfalls identified at the last inspection and consider if there has been sufficient improvement. If we do not believe the registered provider has appropriately addressed the breaches of regulation to the extent” Source location Response from CQC
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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 Update statutory hospital-discharge guidance to support safe, coordinated transfers and continuity of care.
Verbatim wording from the response “This funding is pooled via the Better Care Fund, which requires integrated care boards (ICBs) and local authorities to make joint plans and pool budgets for the purposes of providing more joined-up and effective care. Every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs and who need extra support. Statutory guidance on hospital discharge (updated in January 2024) sets out how local authorities and NHS bodies can ensure that people are discharged safely from hospital to the most appropriate place and continue to receive the care and support they need, taking into account the legal duties in the Health and Care Act 2022.” Source location Response from DHSC
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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 Care home placement shortages and hospital discharge delays fall outside the regulator’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
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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 Secretary of State and Greater Manchester Integrated Care are considered better placed to address care placement shortages and discharge delays.
Verbatim wording from the response “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
Open published response
19 Sep 2024 Evelyn Grace March · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Premature discharge after prolonged labour and induced delivery View source
Linked response
Leeds Teaching Hospitals NHS Trust
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AI-generated summary
Evelyn Grace March · 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
Evelyn Grace March was born after a prolonged labour and was discharged home with her parents four hours later. The following night, while being breastfed in her mother’s bed, she was found unresponsive and could not be revived. The report raises concerns about maternal exhaustion, the early discharge after prolonged labour, and the risk of accidental suffocation while a sleeping adult was in bed with the baby.
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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 Premature discharge after prolonged labour and induced delivery
Wider context from the report “4. Consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and induced delivery . Had she been permitted to sleep in hospital for a few hours knowing that her baby was being monitored, the tragedy may have been avoided.
” Source location Evelyn Grace March · 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 Immediate postnatal care and discharge were considered compliant with national guidance, so earlier discharge arrangements were not changed.
Verbatim wording from the response “I respectfully note that you state that consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and delivery.” Source location Response from Leeds Teaching Hospitals
Open published response
4 Sep 2024 Charles Henry DANIELS · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure to alert a doctor to significant deterioration before discharge home View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Stockport NHS Foundation Trust
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AI-generated summary
Charles Henry DANIELS · 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
Charles Henry Daniels was admitted to Stepping Hill Hospital in January 2024 after a fall and was later discharged home in March despite being described as clearly unwell. He returned to hospital with an acute on chronic subdural bleed and died on 21 March 2024. Concerns included inadequate nursing record-keeping, failure to alert a doctor to his deterioration before discharge, and the distress caused by his condition and discharge arrangements at home.
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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 alert a doctor to significant deterioration before discharge home
Wider context from the report “2) Neither the discharging nurse nor North West Ambulance Service personnel attending Stepping Hill on 6 March 2024, for the purposes of his discharge home, appear to have alerted a doctor to the significant deterioration in Mr Daniel’s condition since last assessed by a doctor on 4 March.
” Source location Charles Henry DANIELS · 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 Existing policy-based escalation was considered sufficient because observations did not warrant medical review before discharge.
Verbatim wording from the response “████████ has further reviewed the record and has confirmed that Mr Daniels’ vital observations did not warrant any escalation to the medical team at any point from 4 March” Source location Response from Stepping Hill Hospital
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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 disputes that significant deterioration was identified on discharge, citing a NEWS of zero throughout the admission.
Verbatim wording from the response “On the day of discharge, the Ward Sister recalls that Mr Daniels required the assistance of three to transfer but due to his variable requirements for assistance with mobility, this did not appear unduly out of character.” Source location Response from Stepping Hill Hospital
Open published response
12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Failure to commence and complete a safety plan during admission and before discharge View source Failure to complete the discharge clinical entry and risk assessment View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr David Thompson · 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 David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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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 commence and complete a safety plan during admission and before discharge
Wider context from the report “1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge .
” Source location Mr David Thompson · 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 complete the discharge clinical entry and risk assessment
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
” Source location Mr David Thompson · Prevention of Future Deaths report
Open source 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 Remind staff to complete required My Safety Plans and monitor compliance through daily dashboard reviews and audits.
Verbatim wording from the response “Issue a reminder to all staff the requirement to complete a My Safety Plan, and to outline the circumstances when a My Safety Plan is required.” Source location Response from Priory Group
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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 Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.
Verbatim wording from the response “Priory Hospital Dorking are to evidence safe discharge planning in accordance with Priory policy H02 Admission, Transfer and Discharge - to include completion of a clinical entry, updated risk assessment on discharge and issue all patients with a crisis card with” Source location Response from Priory Group
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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 NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
Verbatim wording from the response “GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.” Source location Response from Greater Manchester NHS
Open published response
25 Jul 2024 Danny Jay Anderson · Prevention of Future Deaths report East London
View report summary
Concerns raised 2
Lack of safety planning before discharge View source Lack of adequate risk formulation before discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
The Trust
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
View source
The Trust
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
View source
The Trust
Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
View source
The Trust
Provide Trust-wide community mental-health-team training on enhanced transition care planning.
View source
The Trust
Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
View source
The Trust
Re-share the clinical risk policy and provide ward posters on safe discharge steps.
View source
The Trust
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
View source
The Trust
Provide clinical risk-assessment training and apply the clinical risk policy.
View source
The Trust
Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
View source
The Trust
Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
View source
The Trust
Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
View source
The Trust
Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
View source See 9 more actions
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AI-generated summary
Danny Jay 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
Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.
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 safety planning before discharge
Wider context from the report “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023.
The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny.
From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy).
There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022).
Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk.
There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed.
” Source location Danny Jay Anderson · 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 Lack of adequate risk formulation before discharge
Wider context from the report “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023.
The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny.
From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy).
There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022).
Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk.
There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed.
” Source location Danny Jay Anderson · Prevention of Future Deaths report
Open source 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 Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Verbatim wording from the response “The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.” Source location Response from Essex Partnership NHS
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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 Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Verbatim wording from the response “The Trust recognises that there was confusion around responsibilities of the named nurse, which includes risk assessment and formulating risks including plan at point of discharge. The Trust Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes for the named nurse which aims to ensure there is consistent understanding of the named nurse role” Source location Response from Essex Partnership NHS
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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 Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
Verbatim wording from the response “The Trust is on an ongoing journey for improved documentation, which has included training sessions and a specific focus on this within supervision reviews. Work has been undertaken to update the discharge letter template to include discharge planning prompts and the incorporation of carer involvement in the Care Programme Approach review documentation. Discharge letters have been reviewed by the Service User Network Group to review content and tone of correspondence.” Source location Response from Essex Partnership NHS
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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 Provide Trust-wide community mental-health-team training on enhanced transition care planning.
Verbatim wording from the response “Additional training has been undertaken Trust wide in Community Mental Health Teams to support enhanced transition care planning.” Source location Response from Essex Partnership NHS
Open published response
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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 Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
Verbatim wording from the response “and development of our staff with the new Skills Training on Risk Management (STORM) training. This is an evidence-based training methodology given to frontline team members who have the opportunity to practice, reflect, and give and receive feedback on skills in a safe and supportive learning environment. It uses the highest standard level of skills development, which includes filmed skills practice for the more advanced courses. The focus is on the person, collaboration, assessment, and safety planning, and they are joined by new skill sets including Suicide and self-harm – exploring the similarities and differences for assessment. We aim to have 60% of all registered practitioners across all urgent care pathways trained by end of 2024. Achievement of this training roll out is overseen by the Trust’s suicide prevention quality priority group.” Source location Response from Essex Partnership NHS
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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 Re-share the clinical risk policy and provide ward posters on safe discharge steps.
Verbatim wording from the response “In addition we have re-shared the clinical risk policy with staff supported with poster for wards on safety discharge steps” Source location Response from Essex Partnership NHS
Open published response
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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 Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Verbatim wording from the response “Action is already underway as part of the Safety Action Plan to ensure there are clear documented actions agreed at discharge meetings and that the MDT outcome form is completed for each person clearly stating any actions and an overview of relapse signatures and recorded in the patient record.” Source location Response from Essex Partnership NHS
Open published response
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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 Provide clinical risk-assessment training and apply the clinical risk policy.
Verbatim wording from the response “The organisation recognises that the quality of the narrative used in risk assessment is essential for staff to understand risk. This will always be dependent on the staff member completing this. The Trust has clinical risk assessment training in place and a clinical risk policy to guide staff. For ongoing support the Trust has implemented review of risk assessments and documentation completed as part of staff members’ clinical supervision, this enables discussion and immediate learning support for each staff member.” Source location Response from Essex Partnership NHS
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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 Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
Verbatim wording from the response “The Trust has established a new oversight system to enable managers to identify any gaps in risk” Source location Response from Essex Partnership NHS
Open published response
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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 Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
Verbatim wording from the response “As part of all staff one to ones, supervisors work with inpatient named nurses/ community care coordinators reviewing their care plans and risk assessment to check quality of the clinical entries.” Source location Response from Essex Partnership NHS
Open published response
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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 Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
Verbatim wording from the response “In addition the Trust has clinical audit processes which include a record keeping audit and a ‘matron’s records audit’ which includes review of risk formulation and crisis summary. Audit results are taken back to staff and highlighted through discussed in team meetings. The audit process has been reviewed and the Trust now has a person centred audit undertaken where possible with the names nurse to review an individual’s care and documentation thereafter.” Source location Response from Essex Partnership NHS
Open published response
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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 Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
Verbatim wording from the response “Work has been undertaken by the Director NE Essex Community Services, Trust Wide Perinatal, Children’s Learning Disability and Allied Health Professionals Operations to review the role and responsibilities of care coordinators and ongoing quality improvement for risk assessment is part of the Trust Disengagement Safety Improvement Programme” Source location Response from Essex Partnership NHS
Open published response
Concerns raised 2
Lack of a clearly documented and recorded process for patient self-discharge View source Failure to maintain a signed record of patient self-discharge View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Megan Ceris Williams · 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
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
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× 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 clearly documented and recorded process for patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Source location Megan Ceris Williams · 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 maintain a signed record of patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Source location Megan Ceris Williams · Prevention of Future Deaths report
Open source 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 Update and disseminate policies clarifying staff duties for missing patients and patients attempting self-discharge, including patient risk assessment.
Verbatim wording from the response “To ensure a repeat of similar incidents does not re-occur, the Trust has also updated its policy relating to patients who self-discharge from hospital. Enclosed with this letter is the Trust’s updated Missing Persons Policy (Document 7) and the Discharge Criteria policy (Document 8). This has been through 3 separate reviews and updates since May 2022 and ensures that the duties of staff members relating to missing patients and patients who are attempting to self-discharge are clearly established. It also now includes an updated Patient Risk Assessment so that staff members can” Source location Response from East Kent Hospitals
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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 Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.
Verbatim wording from the response “In addition, the Trust has updated the Hospital Discharge and Criteria to Reside Policy. The Policy was updated and issued to all staff at the Trust on 16 February 2023. The updated policy directs staff to always consider the following when a patient indicates that they want to self-discharge:” Source location Response from East Kent Hospitals
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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 Require post-discharge welfare telephone calls for ward patients who self-discharge.
Verbatim wording from the response “Of key importance is that patients are asked to review the Self Discharge Form which must then be filed within the patient’s case notes. The Self Discharge Form sets out the risks of discharging against medical advice and asks a patient to consider these risks before signing the form. This is to ensure that patients have weighed the risks of self-discharge and ensures that there is a recorded process. The Policy also mandates that following discharge, if on a ward, then a welfare check telephone call be made to ensure the patient has arrived home safely.” Source location Response from East Kent Hospitals
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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 No actions by NICE are considered necessary to address the issues raised in the report.
Verbatim wording from the response “On this occasion, we do not consider that there are any actions from NICE that would address the issues raised.” Source location Response from NICE
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns are local Trust issues outside NHS England’s remit.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” Source location Response from NHS England
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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 East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” Source location Response from NHS England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.