Recurring concern

Unreliable transfer of hospital discharge information to prison healthcare

First to latest report 3 Dec 2013 — 10 Aug 2016

Reports that mention this concern: 3
Times this concern has been raised: 7
Stated actions linked to this concern: 1

What this concern includes

Includes failures in the hospital-to-prison process for sending, receiving, routing, making available, acknowledging or reviewing discharge correspondence and related clinical instructions for prisoners, including medication changes, follow-up requirements and important health or welfare information.

What is not included

Excludes general clinical-record, correspondence or information-sharing failures where hospital discharge information to prison healthcare is not the material object.
Excludes failures involving discharge information sent only to GPs, community services or families unless the assertion also concerns transfer to prison healthcare.
Excludes medication-prescribing, administration or treatment failures occurring after complete discharge information was promptly received and reviewed.
Excludes prison-to-community release information and prison-to-court or immigration-detention transfer processes.
Excludes generic prison healthcare access or staffing deficiencies that do not directly impair receipt or review of hospital discharge information.

Trends

Reports over time

Reports mentioning this concern, 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.

Leeds Prison2

Leeds Teaching Hospitals NHS Trust2

Department of Health and Social Care1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

10 Aug2016
West Yorkshire Eastern
Concerns raised3
1. Unavailability of discharge correspondence to prison healthcare staff
2. Failure to review discharge correspondence by prison healthcare staff
3. Breakdown in communication between hospital and prison at discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Care UK
Stated actions 1
1. Care UK
  Create an electronic pathway to share hospital discharge summaries with HMP Leeds.
AI-generated summary

Thomas George Jordan · 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

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

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
Unavailability of discharge correspondence to prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Source location
Thomas George Jordan · 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 review discharge correspondence by prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Source location
Thomas George Jordan · 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
Breakdown in communication between hospital and prison at discharge
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Source location
Thomas George Jordan · 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
Create an electronic pathway to share hospital discharge summaries with HMP Leeds.

Verbatim wording from the response
“Further to that correspondence, the Head of Healthcare at HMP Leeds has discussed the above with the Clinical Director for Urgent Care at Leeds Teaching Hospital. The Director has agreed that an electronic summary can be issued with all patients who transfer back to HMP Leeds following discharge from a hospital admission. The Hospital currently send an electronic summary to the registered GP and the process for sending the same to the prison can be incorporated within their system. IT personnel from both the Hospital and Care UK will create a pathway that ensures all summaries are appropriately shared. In the meantime, the Director will ensure that written summaries are provided in a sealed envelope for all hospital discharges and these will accompany the patient back to the prison.”

Source location
Response from Care UK
Page 1 · response
Published 10 August 2016
Open published response
10 Aug2016
West Yorkshire Eastern
Concerns raised3
1. Breakdown in hospital-to-prison discharge communication
2. Delayed availability of discharge correspondence to prison healthcare staff
3. Failure by prison healthcare staff to review discharge correspondence
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas George Jordan · 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

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

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
Breakdown in hospital-to-prison discharge communication
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Source location
Thomas George Jordan · 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
Delayed availability of discharge correspondence to prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Source location
Thomas George Jordan · 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 by prison healthcare staff to review discharge correspondence
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Source location
Thomas George Jordan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Dec2013
Manchester City
Concerns raised1
1. Failure to provide prison healthcare professionals with timely and complete discharge information
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Horace Cottom · Prevention of Future Deaths report

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

Report summary

Horace Cottom, a serving prisoner at HMP Manchester, died there on 21 June 2012 from pneumonia and heart disease with pseudomembranous colitis, with the inquest concluding that the death was from natural causes. The principal concern was that discharge information from NHS hospitals could take about 10 days to reach the prison and was sometimes incomplete, affecting the timely management of prisoners’ healthcare after hospital discharge.

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