17 Apr 2024 Mr Timothy Charles Clayton · Prevention of Future Deaths report Surrey
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Concerns raised 2
Failure to ensure a care plan is in place before discharge View source Failure to protect properly considered discharge planning from bed-space pressure View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Epsom and St Helier University Hospitals NHS Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
NHS England
Establish care transfer hubs across hospitals to coordinate discharges for patients with complex needs.
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NHS England
Continue improving in-hospital discharge through early planning and early involvement of patients, carers, families and care transfer hubs.
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Epsom and St Helier University Hospitals NHS Trust
Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.
View source
Epsom and St Helier University Hospitals NHS Trust
Embed safe discharge checklists into clinical practice and review discharge practice following the incident investigation.
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Epsom and St Helier University Hospitals NHS Trust
Conduct weekly local discharge audits and a Trust-wide audit to monitor compliance with the revised discharge policy.
View source
NHS England
Provide additional acute bed capacity, supported by capital investment, to improve hospital flow and reduce discharge pressure.
View source
Epsom and St Helier University Hospitals NHS Trust
Strengthen discharge escalation pathways and communicate safe-discharge expectations through senior-leadership presentations and staff communications.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure 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
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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 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
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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 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
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, 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
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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 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
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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 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
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How this respondent action was interpreted
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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
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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 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
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12 Apr 2024 Sabina Wood · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 2
Failure to prepare discharge summaries only when patients are ready for discharge View source Failure of the discharge-summary IT system to verify completion before marking documents complete View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the 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
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 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
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2 Apr 2024 Andrew Ewin-Ripp · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to require practitioners to pass essential epilepsy information to patients on discharge View source
This report raised 6 other concerns. 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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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.
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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 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
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21 Mar 2024 Sarah Elizabeth ADAMS · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Lack of training for practitioners in the discharge process, including issues arising from out of area admissions View source
Linked responses
Berkshire Healthcare NHS Foundation Trust Cygnet Health Care Limited Reading Borough Council
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
Cygnet Health Care Limited
Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
View source
Cygnet Health Care Limited
Update risk e-learning guidance to address risk assessment around discharge.
View source
Cygnet Health Care Limited
Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
View source
Berkshire Healthcare NHS Foundation Trust
Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
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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.
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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 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
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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 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
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 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
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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 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
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21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to provide clear and understandable discharge information and 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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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and 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
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9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission City Health Care Partnership CIC Hull University Teaching Hospitals NHS Trust NHS England St Andrews Surgery
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
Hull University Teaching Hospitals NHS Trust
Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
View source
NHS England
Advance national programmes to improve access to and sharing of patient information between NHS and private providers.
View source
City Health Care Partnership CIC
Participate in HUTH’s time-limited task group to explore digital discharge-planning solutions for patients with complex wounds or pressure ulcers.
View source
St Andrews Surgery
Provide staff training and updates on accurate, detailed patient-record documentation and good record-keeping.
View source
St Andrews Surgery
Recruit a Data Quality and IT Officer to oversee data-quality audits and provide training where applicable.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of 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
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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 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
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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 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
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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 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
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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 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
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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 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
Open published response
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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 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
Open published response
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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 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
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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 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
Open published response
4 Mar 2024 Sarah Rhiannon Keen · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Failure to document and communicate discharge medication recommendations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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
Open source 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 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
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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 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
Open published response
16 Feb 2024 Sobia Tabasim Khan · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3
Failure to provide clinicians with full risk-assessment reports for discharge decisions View source Inadequate and misleading risk and progress reports for restricted-patient discharge View source Failure to complete and consider a pre-discharge family assessment View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cygnet Health Care Limited Derby City Council Derbyshire Healthcare NHS Foundation Trust Ministry of Justice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Derby City Council
Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.
View source
Ministry of Justice
Update community leave and discharge application forms to require more detail on MAPPA engagement and victims.
View source
Cygnet Health Care Limited
Provide full SARA documents in professionals’ CPA and section 117 meeting report packs.
View source
Cygnet Health Care Limited
Send the full SARA document to the Ministry of Justice with section 17 leave applications and indicate its availability on discharge requests.
View source
Cygnet Health Care Limited
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.
View source
Derbyshire Healthcare NHS Foundation Trust
Train Forensic Community Mental Health Team clinicians in report writing to required forensic standards.
View source
Ministry of Justice
Refresh and improve the reporting tool used to update the Secretary of State on restricted patients’ community progress.
View source
Cygnet Health Care Limited
Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.
View source See 5 more actions
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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.
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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 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
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
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
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 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
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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 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
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 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
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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 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
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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 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
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 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
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 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
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 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
Open published response
5 Feb 2024 Georgia Dehaney-Perkins · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to record agreed family medication-management mitigations in the discharge care plan View source Failure to update and communicate fixed-point ligature risks in discharge planning View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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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
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
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 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
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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 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
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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 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
Open published response
Concerns raised 2
Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities View source Delays and failures in transferring and acting on discharge clinical documentation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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
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 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
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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 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
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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 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
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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 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
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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 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
Open published response
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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 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.