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.

17 Apr2024
Surrey
Concerns raised2
1. Failure to ensure a care plan is in place before discharge
2. Failure to protect properly considered discharge planning from bed-space pressure
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Establish care transfer hubs across hospitals to coordinate discharges for patients with complex needs.
  Stated by NHS EnglandStated completed
2. Action
  Continue improving in-hospital discharge through early planning and early involvement of patients, carers, families and care transfer hubs.
  Stated by NHS EnglandStated in progress
3. Action
  Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
1. Action
  Embed safe discharge checklists into clinical practice and review discharge practice following the incident investigation.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
2. Action
  Conduct weekly local discharge audits and a Trust-wide audit to monitor compliance with the revised discharge policy.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
3. Action
  Provide additional acute bed capacity, supported by capital investment, to improve hospital flow and reduce discharge pressure.
  Stated by NHS EnglandStated completed
4. Action
  Strengthen discharge escalation pathways and communicate safe-discharge expectations through senior-leadership presentations and staff communications.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
AI-generated summary

Mr Timothy Charles Clayton · 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 Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure a care plan is in place before discharge
Wider context from the report
“2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him. Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity. ”
Source location
Mr Timothy Charles Clayton · Prevention of Future Deaths report
Page 3 · 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 protect properly considered discharge planning from bed-space pressure
Wider context from the report
“3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making. ”
Source location
Mr Timothy Charles Clayton · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish care transfer hubs across hospitals to coordinate discharges for patients with complex needs.

Verbatim wording from the response
“plan was the requirement that all Trusts work together with local authorities and system partners to establish a Care Transfer Hub to manage discharges for patients with more complex needs.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2024
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
Continue improving in-hospital discharge through early planning and early involvement of patients, carers, families and care transfer hubs.

Verbatim wording from the response
“The Urgent and emergency care recovery plan year 2: Building on learning from 2023/24, published in May 2024, sets out commitment to continue to improve in-hospital discharge processes by ensuring early discharge planning, including the effective involvement of patients, carers and families, in line with statutory guidance. Acute providers are asked to continue to improve in-hospital processes to improve timeliness of discharge, including early discharge planning from the point of admission and early involvement of care transfer hubs where patients are likely to have more complex discharge needs.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.

Verbatim wording from the response
“The Root Cause Analysis undertaken following this incident identified the fact that Mr Clayton was a vulnerable adult and so a complex discharge pathway should have been triggered as required within the Trust’s discharge policy. As a result of this investigation, the principles of effective discharge processes were reviewed, safe check lists embedded into practice and clinical practice reviewed. Subsequent to the Inquest the Hospital Discharge and Criteria to Reside Policy (ESTH/POL/64521) has been reviewed, updated and approved and shared with staff in the organisation. This policy provides clarity on the identification of vulnerable patients for discharge and outlines the responsibilities of patients, family and carers to be included in the discharge planning. The policy encourages families to raise concerns and, where concerns are raised, supports how these are managed.”

Source location
Response from St George's, Epsom and St Helier
Page 3 · response
Published 29 April 2024
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
Embed safe discharge checklists into clinical practice and review discharge practice following the incident investigation.

Verbatim wording from the response
“The Root Cause Analysis undertaken following this incident identified the fact that Mr Clayton was a vulnerable adult and so a complex discharge pathway should have been triggered as required within the Trust’s discharge policy. As a result of this investigation, the principles of effective discharge processes were reviewed, safe check lists embedded into practice and clinical practice reviewed. Subsequent to the Inquest the Hospital Discharge and Criteria to Reside Policy (ESTH/POL/64521) has been reviewed, updated and approved and shared with staff in the organisation. This policy provides clarity on the identification of vulnerable patients for discharge and outlines the responsibilities of patients, family and carers to be included in the discharge planning. The policy encourages families to raise concerns and, where concerns are raised, supports how these are managed.”

Source location
Response from St George's, Epsom and St Helier
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct weekly local discharge audits and a Trust-wide audit to monitor compliance with the revised discharge policy.

Verbatim wording from the response
“The effectiveness of the new policy will be reviewed through a planned Trust-wide audit in November 2024 which will be presented and any actions resulting from this monitored by the Patient Safety and Quality Group.”

Source location
Response from St George's, Epsom and St Helier
Page 3 · response
Published 29 April 2024
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 additional acute bed capacity, supported by capital investment, to improve hospital flow and reduce discharge pressure.

Verbatim wording from the response
“The delivery plan for recovering urgent and emergency care services committed to providing the NHS with additional bed capacity to improve hospital flow and performance. The target of 5,000 additional core general and acute beds, against previously planned levels, was met and consistently exceeded in January 2024, supported by £250 million for 30 capital schemes across the country. 2024/25 operational planning guidance sets out an ask for systems to maintain their levels of acute core general and acute beds in 2024/25, and to expand their bedded and non-bedded intermediate care capacity, through the additional £400 million distributed via the Better Care Fund (BCF), to support improvements in hospital discharge and enable step-up care in the community.”

Source location
Response from NHS England
Page 1 · response
Published 29 April 2024
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
Strengthen discharge escalation pathways and communicate safe-discharge expectations through senior-leadership presentations and staff communications.

Verbatim wording from the response
“As a result of the Inquest and the concerns raised, the Trust has revised the discharge policy to ensures that the processes to gather the information required, the responsibilities of clinicians and the escalation processes for safe, timely and appropriate discharge of patients are clear. Staff have been encouraged to escalate to their senior managers when they have concerns regarding discharge through the Topic of the Week. The Site Chief Medical Officer and Site Chief Nursing Officer has presented this at key senior leadership meetings including the Clinical Leads meeting, Divisional Senior Leadership Team meeting and Divisional Medical Directors meetings. Escalation processes have been strengthened to ensure that there is a clear pathway for concerns for clinical and clinical operational teams within working hours and out of hours.”

Source location
Response from St George's, Epsom and St Helier
Page 7 · response
Published 29 April 2024
Open published response
12 Apr2024
Blackpool and the Fylde
Concerns raised2
1. Failure to prepare discharge summaries only when patients are ready for discharge
2. Failure of the discharge-summary IT system to verify completion before marking documents complete
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 2
1. Action
  Issue a safety instruction directing staff to take care when pre-populating discharge summaries and avoid prejudging investigation results.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Implement the integrated NPR eDischarge system with auto-population and password safeguards preventing incomplete discharge summaries from being issued.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Sabina Wood · Prevention of Future Deaths report

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

Report summary

Sabina Wood was admitted to hospital with abdominal pain, gallstones and possible bile duct stones, underwent an ERCP, and self-discharged against medical advice. She was found unresponsive at home on 27 January 2023 and her death was recorded as a natural death, with acute haemorrhagic pancreatitis and cholelithiasis stated as the medical cause. The principal concern was that a speculative and inaccurate draft discharge summary, prepared before the ERCP and sent to her GP practice, reflected unsafe processes and could pose a risk to future patients.

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 prepare discharge summaries only when patients are ready for discharge
Wider context from the report
“I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest. I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital. In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling. ████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████. ████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts. I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries. I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care. I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases. For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific. I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ”
Source location
Sabina Wood · 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 of the discharge-summary IT system to verify completion before marking documents complete
Wider context from the report
“I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest. I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital. In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling. ████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████. ████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts. I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries. I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care. I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases. For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific. I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ”
Source location
Sabina Wood · 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
Issue a safety instruction directing staff to take care when pre-populating discharge summaries and avoid prejudging investigation results.

Verbatim wording from the response
“In the interim whilst system implementation is brought to completion, the Executive Medical Director will issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need to take care when pre-populating and that clinicians are not to prejudge any investigation results.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 29 April 2024
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
Implement the integrated NPR eDischarge system with auto-population and password safeguards preventing incomplete discharge summaries from being issued.

Verbatim wording from the response
“With regard to the IT system in place to provide discharge summaries, to which your concern relates, the Trust are in the process of replacing the current eDischarge product with one integrated system built upon the Trust’s Nexus NPR platform, developed in house by our Application Development Team.”

Source location
Response from Blackpool Teaching Hospitals
Page 1 · response
Published 29 April 2024
Open published response
2 Apr2024
East London
Concerns raised1
1. Failure to require practitioners to pass essential epilepsy information to patients on discharge
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Andrew Ewin-Ripp · Prevention of Future Deaths report

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

Report summary

Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.

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 require practitioners to pass essential epilepsy information to patients on discharge
Wider context from the report
“There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern: (1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures. (2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this. (3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge. (4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication. ”
Source location
Andrew Ewin-Ripp · Prevention of Future Deaths report
Page 3 · concerns
Open source report
21 Mar2024
Berkshire
Concerns raised1
1. Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
  Stated by Cygnet Health Care LimitedStated completed
2. Action
  Update risk e-learning guidance to address risk assessment around discharge.
  Stated by Cygnet Health Care LimitedStated planned
3. Action
  Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
  Stated by Cygnet Health Care LimitedStated in progress
1. Action
  Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
  Stated by Berkshire Healthcare NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.
  Stated by Reading Borough CouncilExisting arrangements considered sufficient
AI-generated summary

Sarah Elizabeth ADAMS · 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

Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.

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 training for practitioners in the discharge process, including issues arising from out of area admissions
Wider context from the report
“That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions ”
Source location
Sarah Elizabeth ADAMS · 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
Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.

Verbatim wording from the response
“Care planning and risk assessment training is provided to staff to support them in completing care plans, including discharge care plans. This is via a 4.5 hour face to face session. The session is provided by the Regional Nursing Director to all the Clinical Managers to then be cascaded at each site. At Cygnet Harrow this session has been provided to all members of the multi-disciplinary team (MDT) and is due to be refreshed on an annual basis, or more frequently if a need is identified.”

Source location
Response from Cygnet Healthcare
Page 1 · response
Published 3 April 2024
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
Update risk e-learning guidance to address risk assessment around discharge.

Verbatim wording from the response
“This training is aligned with Cygnet's broader training offering, particularly our e-learning risk training. This training is provided to all members of the MDT and refreshed on a two-yearly basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and ensuring that risk assessments are of high quality and triangulated with the care plans, continuous notes and information from families and carers. We are acutely aware that risks can increase at discharge and that risk assessments need to be undertaken carefully to ensure that we implement steps to minimise this. The risk training has been reviewed and from 1 July 2024 will include updated and more specific guidance in relation to risk assessing around discharge.”

Source location
Response from Cygnet Healthcare
Page 1 · response
Published 3 April 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.

Verbatim wording from the response
“Further, a supplemental set of training slides for staff induction are in development to provide support to staff in understanding the content of the discharge policy, including the discharge checklist, the key risks to consider, accurate documentation and communication with community teams. These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites to assist new staff with prompt familiarisation with our processes.”

Source location
Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024
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
Implement revised Clinical Risk training with increased focus on high-risk discharge situations.

Verbatim wording from the response
“All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:”

Source location
Response from Berkshire Healthcare NHS Foundation Trust
Page 1 · response
Published 3 April 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.

Verbatim wording from the response
“9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.”

Source location
Response from Reading Borough Council
Page 2 · response
Published 3 April 2024
Open published response
21 Mar2024
South Wales Central
Concerns raised1
1. Failure to provide clear and understandable discharge information and assessment
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
  Stated by Cardiff & Vale University LHBStated completed
AI-generated summary

Alan Richard Miles Davies · 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

Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide clear and understandable discharge information and assessment
Wider context from the report
“(2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison ”
Source location
Alan Richard Miles Davies · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.

Verbatim wording from the response
“Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a reliable route for sharing information across organisations to mitigate information-related risks. The protocol also identifies”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 25 March 2024
Open published response
9 Mar2024
East Riding and Hull
Concerns raised1
1. Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
  Stated by Hull University Teaching Hospitals NHS TrustStated in progress
2. Action
  Advance national programmes to improve access to and sharing of patient information between NHS and private providers.
  Stated by NHS EnglandStated in progress
3. Action
  Participate in HUTH’s time-limited task group to explore digital discharge-planning solutions for patients with complex wounds or pressure ulcers.
  Stated by City Health Care Partnership CICStated in progress
1. Action
  Provide staff training and updates on accurate, detailed patient-record documentation and good record-keeping.
  Stated by St Andrews SurgeryStated completed
2. Action
  Recruit a Data Quality and IT Officer to oversee data-quality audits and provide training where applicable.
  Stated by St Andrews SurgeryStated completed
Respondent positions 3
1. Position
  The material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.
  Stated by Hull University Teaching Hospitals NHS TrustDisputes the concern
1. Position
  Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
  Stated by NHS EnglandRedirects responsibility
2. Position
  Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
AI-generated summary

Linda Heath · 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 Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.

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 immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report
“(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. ”
Source location
Linda Heath · 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
Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.

Verbatim wording from the response
“In relation to the immediate discharge summary this is a document completed by medical staff, and is intended to be a summary of the medical care. There are ongoing discussions about the level of information that should be included within the form, as it is important it does not become too lengthy, but the Trust is of the view that in order to prevent the problem that occurred in Linda’s case, the issue to be addressed is ensuring that appropriate referrals are made in the first place, by the Trust at the point of discharge. In Linda’s case if the discharge summary had noted the need for community nursing referral it is true that it is possible the GP could have followed this up, but in fairness it would not be the GP’s responsibility to do that. In Linda’s case she proactively sought input from her GP and their involvement was discussed at the Inquest.”

Source location
Response from HUTH
Page 2 · response
Published 14 May 2024
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
Advance national programmes to improve access to and sharing of patient information between NHS and private providers.

Verbatim wording from the response
“Nationally, there are several programmes of work underway to improve access to and the sharing of patient information between providers, both NHS and private. These include the National Care Records Service and Shared Care Records.”

Source location
Response from NHS England
Page 2 · response
Published 14 May 2024
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
Participate in HUTH’s time-limited task group to explore digital discharge-planning solutions for patients with complex wounds or pressure ulcers.

Verbatim wording from the response
“The preferable solution to transferring care between CHCP and HUTH would be a digital solution between the two ECRs. CHCP TVNs are currently attending a time limited Task and Finish Group established by HUTH in relation to exploring discharge planning for patients with complex wounds/pressure ulcers and seek a digital solution. This Task and Finish Group is in addition to the Triangulation meetings.”

Source location
Response from City Healthcare Partnership Hull
Page 3 · response
Published 14 May 2024
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 staff training and updates on accurate, detailed patient-record documentation and good record-keeping.

Verbatim wording from the response
“2. Training: Additional training and updates have been provided to all staff regarding the importance of good record-keeping. This includes understanding the significance of accurate and detailed documentation in the patient record. We have recently recruited a Data Quality and IT Officer to oversee and ensure that data is of a high standard through audits and training where applicable.”

Source location
Response from GP Surgery
Page 1 · response
Published 14 May 2024
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
Recruit a Data Quality and IT Officer to oversee data-quality audits and provide training where applicable.

Verbatim wording from the response
“2. Training: Additional training and updates have been provided to all staff regarding the importance of good record-keeping. This includes understanding the significance of accurate and detailed documentation in the patient record. We have recently recruited a Data Quality and IT Officer to oversee and ensure that data is of a high standard through audits and training where applicable.”

Source location
Response from GP Surgery
Page 1 · response
Published 14 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.

Verbatim wording from the response
“Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest in relation to points 1 and 4. Points 2 and 3 relate to primary care.”

Source location
Response from HUTH
Page 1 · response
Published 14 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.

Verbatim wording from the response
“Your Report raises some concerns that would be more appropriately answered by the providers involved in Linda’s care, who I note you have also addressed your Report to. My response to your focuses on those areas that fall within the remit of NHS England’s national policy and programmes, although my regional colleagues have engaged with the Humber and North Yorkshire Health and Care Partnership on the concerns raised, as this is system in which the providers involved in Linda’s care operate.”

Source location
Response from NHS England
Page 1 · response
Published 14 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.

Verbatim wording from the response
“During the inspection process we routinely review correspondence, tasks and referrals. We will use the regulation 28 report to remind colleagues of the importance of this process.”

Source location
Response from CQC
Page 3 · response
Published 14 May 2024
Open published response
4 Mar2024
Mid Kent and Medway
Concerns raised1
1. Failure to document and communicate discharge medication 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.
Actions described in response 2
1. Action
  Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
  Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclear
2. Action
  State in discharge notifications when medication has been reduced and record the reason.
  Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclear
AI-generated summary

Sarah Rhiannon Keen · 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

Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.

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 document and communicate discharge medication recommendations
Wider context from the report
“(2) The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that Sarah’s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide Sarah with any medication on the basis that there was already a prescription in the community and although he considered that it was appropriate for the quantity of discharge medication to be reduced to seven days to reduce the risk of overdose, he did not communicate this to the medical team within the note. ”
Source location
Sarah Rhiannon Keen · 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
Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.

Verbatim wording from the response
“• The discharging clinician (both or either DGT and KMPT) should record if a reduced amount of medication should be prescribed because of risk of self-harm or overdose.”

Source location
Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Page 2 · response
Published 14 March 2024
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
State in discharge notifications when medication has been reduced and record the reason.

Verbatim wording from the response
“• The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.”

Source location
Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Page 2 · response
Published 14 March 2024
Open published response
16 Feb2024
Derby and Derbyshire
Concerns raised3
1. Failure to provide clinicians with full risk-assessment reports for discharge decisions
2. Inadequate and misleading risk and progress reports for restricted-patient discharge
3. Failure to complete and consider a pre-discharge family assessment
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.
  Stated by Derby City CouncilStated completed
2. Action
  Update community leave and discharge application forms to require more detail on MAPPA engagement and victims.
  Stated by Ministry of JusticeStated completed
3. Action
  Provide full SARA documents in professionals’ CPA and section 117 meeting report packs.
  Stated by Cygnet Health Care LimitedStated completed
1. Action
  Send the full SARA document to the Ministry of Justice with section 17 leave applications and indicate its availability on discharge requests.
  Stated by Cygnet Health Care LimitedStated planned
2. Action
  Monitor and audit section 117 and transfer-of-care meetings to ensure current reports or addenda and detailed minutes are recorded, focusing on specified high-risk discharges.
  Stated by Cygnet Health Care LimitedStated completed
3. Action
  Train Forensic Community Mental Health Team clinicians in report writing to required forensic standards.
  Stated by Derbyshire Healthcare NHS Foundation TrustStated completed
4. Action
  Refresh and improve the reporting tool used to update the Secretary of State on restricted patients’ community progress.
  Stated by Ministry of JusticeStated completed
5. Action
  Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.
  Stated by Cygnet Health Care LimitedStated completed
AI-generated summary

Sobia Tabasim Khan · 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

Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

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 clinicians with full risk-assessment reports for discharge decisions
Wider context from the report
“f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given ████████ risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection. ”
Source location
Sobia Tabasim Khan · Prevention of Future Deaths report
Page 3 · 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
Inadequate and misleading risk and progress reports for restricted-patient discharge
Wider context from the report
“a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced. ”
Source location
Sobia Tabasim Khan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete and consider a pre-discharge family assessment
Wider context from the report
“i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered. ”
Source location
Sobia Tabasim Khan · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.

Verbatim wording from the response
“The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher.”

Source location
Response from Derby City Council
Page 2 · response
Published 22 February 2024
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
Update community leave and discharge application forms to require more detail on MAPPA engagement and victims.

Verbatim wording from the response
“In March 2022 MHCS updated application forms for community leave and discharge applications requiring increased detail around MAPPA engagement and victims with the aim of improving the quality and completeness of the information submitted to the MHCS.”

Source location
Response from Ministry of Justice
Page 1 · response
Published 22 February 2024
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 full SARA documents in professionals’ CPA and section 117 meeting report packs.

Verbatim wording from the response
“1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).”

Source location
Response from Cygnet
Page 2 · response
Published 22 February 2024
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
Send the full SARA document to the Ministry of Justice with section 17 leave applications and indicate its availability on discharge requests.

Verbatim wording from the response
“1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).”

Source location
Response from Cygnet
Page 2 · response
Published 22 February 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor and audit section 117 and transfer-of-care meetings to ensure current reports or addenda and detailed minutes are recorded, focusing on specified high-risk discharges.

Verbatim wording from the response
“3. Section 117 and transfer of care meetings are monitored and audited at Cygnet Derby to ensure up to date reports or addendums are submitted, and detailed minutes recorded, the main focus being on MoJ, MAPPA, and high profile service user discharges.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 2024
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
Train Forensic Community Mental Health Team clinicians in report writing to required forensic standards.

Verbatim wording from the response
“The Trust is conscious that clinical teams, the Ministry of Justice and the MHRT rely on the information that is provided to them to consider risk and understand their own role in a patient’s care. To that end the Trust’s FCMHT has been provided with training on report writing to ensure that the information contained within the reports that it writes (to other clinicians, to MHRT and to the MoJ) are of the standards associated with a FCMHT.”

Source location
Response from Derbyshire Healthcare NHS Foundation Trust
Page 2 · response
Published 22 February 2024
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
Refresh and improve the reporting tool used to update the Secretary of State on restricted patients’ community progress.

Verbatim wording from the response
“patients, it covers all aspects of a patient’s discharge into the community. At the same time, the reporting tool that is used to keep the Secretary of State updated with regards to a restricted patient’s progress in the community was also refreshed and improved.”

Source location
Response from Ministry of Justice
Page 2 · response
Published 22 February 2024
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
Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.

Verbatim wording from the response
“1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 2024
Open published response
5 Feb2024
Essex
Concerns raised2
1. Failure to record agreed family medication-management mitigations in the discharge care plan
2. Failure to update and communicate fixed-point ligature risks in discharge planning
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Share discharge plans with involved professionals and consented families or carers, and prompt staff to check agreed medication plans.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Update the General Workplace Risk Assessment to include the fixed-point ligature.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Undertake multidisciplinary discussions to develop and review individualised care plans and risk assessments during discharge planning.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Georgia Dehaney-Perkins · 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

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

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 record agreed family medication-management mitigations in the discharge care plan
Wider context from the report
“(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
Source location
Georgia Dehaney-Perkins · Prevention of Future Deaths report
Page 3 · 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 update and communicate fixed-point ligature risks in discharge planning
Wider context from the report
“(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete ”
Source location
Georgia Dehaney-Perkins · 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
Share discharge plans with involved professionals and consented families or carers, and prompt staff to check agreed medication plans.

Verbatim wording from the response
“In order to strengthen safety measures in relation to this concern the wards now have in place that post each discharge meeting, discharge plans are shared with all health professionals and family/carers (with consent) involved in the care of the patient. A prompt is now written in the diary to remind staff to check the discharge plan that has been agreed for that patient including medication plans.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 14 February 2024
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
Update the General Workplace Risk Assessment to include the fixed-point ligature.

Verbatim wording from the response
“The General Workplace Risk Assessment has been updated to include the fixed-point ligature. Multi-disciplinary team discussions are being undertaken to develop and to review individualised care plans and risk assessments as part of discharge planning.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 14 February 2024
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
Undertake multidisciplinary discussions to develop and review individualised care plans and risk assessments during discharge planning.

Verbatim wording from the response
“The General Workplace Risk Assessment has been updated to include the fixed-point ligature. Multi-disciplinary team discussions are being undertaken to develop and to review individualised care plans and risk assessments as part of discharge planning.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 14 February 2024
Open published response
2 Feb2024
North Wales (East and Central)
Concerns raised2
1. Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities
2. Delays and failures in transferring and acting on discharge clinical documentation
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.
Actions described in response 3
1. Action
  Hold formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
3. Action
  Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
Respondent positions 3
1. Position
  The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
  Stated by Elysium Healthcare LimitedDisputes the concern
1. Position
  Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
  Stated by Elysium Healthcare LimitedUnable to act
2. Position
  The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
  Stated by Elysium Healthcare LimitedExisting arrangements considered sufficient
AI-generated summary

Philip David Taylor · 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

Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.

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 joint discharge planning between the Health Board and out-of-area psychiatric facilities
Wider context from the report
“b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s discharge. ”
Source location
Philip David Taylor · 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
Delays and failures in transferring and acting on discharge clinical documentation
Wider context from the report
“c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged. d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon. In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor, even where there was a change in medication dosage. ”
Source location
Philip David Taylor · 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
Hold formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.

Verbatim wording from the response
“All areas have stood up a formal weekly out of area monitoring meeting. The purpose of this meeting is to promote timely repatriation where possible, assurance that key clinical activity and standards are being met and that discharge plans are being implemented and actioned. These meetings are underpinned by terms of reference, agenda, minutes and a log of actions to be completed. Membership includes the multidisciplinary team, including Health and Social Care, Consultant and Medical staffing, Occupational Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior Leadership meeting to ensure appropriate escalation arrangements can be put in place where required.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.

Verbatim wording from the response
“The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
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
Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.

Verbatim wording from the response
“A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.

Verbatim wording from the response
“5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by”

Source location
Response from Elysium Healthcare
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.

Verbatim wording from the response
“2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.”

Source location
Response from Elysium Healthcare
Page 2 · response
Published 12 February 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.

Verbatim wording from the response
“The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.”

Source location
Response from Elysium Healthcare
Page 3 · response
Published 12 February 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure a care plan is in place before discharge

Failure to protect properly considered discharge planning from bed-space pressure

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.7

Concerns raised2

Failure to prepare discharge summaries only when patients are ready for discharge

Failure of the discharge-summary IT system to verify completion before marking documents complete

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to require practitioners to pass essential epilepsy information to patients on discharge

Concerns raised1

Lack of training for practitioners in the discharge process, including issues arising from out of area admissions

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.4

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

Concerns raised1

Failure to provide clear and understandable discharge information and assessment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 7

Actions described in response 2

Actions described in response 4

Respondent positions 1

Actions described in response 1

Actions described in response 5

Respondent positions 3