Recurring concern

Failure to involve families and carers in discharge planning and decisions

First to latest report 30 Jan 2013 — 7 Nov 2025

Reports that mention this concern
35
Times this concern has been raised
40
Stated actions linked to this concern
36

What this concern includes

Includes failures in the discharge process to identify appropriate families or carers, seek and consider their views or information, involve them in complex discharge planning and decisions, and communicate material arrangements or risks to them where involvement is appropriate.

What is not included
  • Excludes failures in family or carer involvement outside discharge planning or discharge decisions.
  • Excludes communication solely between professionals, services or receiving organisations where family or carer involvement is not the unsafe condition.
  • Excludes failures limited to the clinical suitability of a discharge, housing, care-package provision or equipment unless the report also identifies exclusion of relevant families or carers from the discharge process.
  • Excludes mental-health care-planning involvement where discharge is not materially part of the asserted concern.

Reports and published responses 35 reports

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

  1. Kent and Medway

    AI-generated summary

    Ernest Roy Gray · 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

    Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.

    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 involve the patient’s cohabiting carer in discharge planning

    Wider context from the report

    “(1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer. ”

    Source location

    Ernest Roy Gray · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Request and develop IT record changes to distinguish carers from next of kin.

    Verbatim wording from the response

    “1. We have requested IT record changes to correctly identify the carer(s) involved so they can be involved in appropriate discussions and decisions. Our current IT systems do not allow us to differentiate ‘carer’ from ‘next of kin’ (they can be different as was the case with Mr Gray). We recognise that this will be key in clearly identifying the carer for future discharge conversations so we have raised this urgently with the Sunrise team to investigate. The request has been made and is being prioritised.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit identification of carers and their support needs among patients aged 70 or over.

    Verbatim wording from the response

    “2. We carried out a snapshot audit in January 2026 of a sample of up to 50 patients aged 70 or over to specifically investigate how their carer is currently identified on our IT systems and from then, what support the carer may require to give assurances that the Carer’s Policy and Discharge Policy is being followed. Early findings as is frequently seen; is that families of confused patients are becoming exhausted and unable to cope. They are currently only identified as ‘NOK’, followed by their relationship (son, daughter) and not whether they are the carer. The planned addition of the NOK field will allow for easier audits and monitoring in the future.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.

    Verbatim wording from the response

    “3. We have allocated an experienced discharge advisor to a new Carer’s Champion post. This individual has been identified, and they commenced their role in early January. They will support the ward multi-disciplinary teams to identify the patient’s carer and ensure that the carer themselves is involved in the discharge discussions from early in the admission.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 2 · response
    Published 14 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Re-audit progress on carer identification and support in February, March and April.

    Verbatim wording from the response

    “9. Mapping of Progress by re-audit by the Carers Champion will take place in February, March and April this year.”

    Source location

    Response from East Kent Hospitals University NHS Foundation Trust
    Page 4 · response
    Published 14 November 2025

    Open published response

  2. Oxfordshire

    AI-generated summary

    Cain Alex River Donald · 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

    Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

    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 engage family members effectively in discharge planning

    Wider context from the report

    “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

    Source location

    Cain Alex River Donald · 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

    Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.

    Verbatim wording from the response

    “More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 17 June 2025

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Esther Jane Lancaster Byrne · 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

    Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.

    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 communicate diagnosis, treatment options, rationale and discharge plans with family representatives

    Wider context from the report

    “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. ”

    Source location

    Esther Jane Lancaster Byrne · 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

    Allocate a multidisciplinary team member on ward rounds to update families about all aspects of patient care.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct regular retrospective clinical-record audits to monitor compliance with family communication standards.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

    Open published response

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

    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 further explore a patient's decision not to involve a relevant family member in discharge notification

    Wider context from the report

    “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024. 1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes. 2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further. You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded. ”

    Source location

    Callum James Hargreaves · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Essex

    AI-generated summary

    DARREN NEIL TURNER · 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

    Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.

    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 liaise with family to establish discharge suitability and safety

    Wider context from the report

    “(e) Failures in Communication including a failure to appropriately liaise with the deceased’s Family and, specifically, Darren’s mother to establish the suitability and safety of a discharge to her address not least in the context of Darren’s disclosure that discharge to his mother’s home might “make him feel worse” at a point in time that he later acknowledged “would be overwhelming” for him. ”

    Source location

    DARREN NEIL TURNER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.

    Verbatim wording from the response

    “The Trust has established family ambassadors on the wards who are a key point of contact for families and are responsible for ensuring information shared by families is recorded and considered by the MDT.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 3 · response
    Published 17 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.

    Verbatim wording from the response

    “Additionally, on discharge, an allocated registered nurse on shift will take responsibility for working with the patient to prepare for safe discharge including home travel plans, ensuring support network plan is in place, contact / follow up advice and crisis contingency plan.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.

    Verbatim wording from the response

    “This 10 year thematic review of in-patient deaths informed the Discharge SIP and contributed to the development of a new in patient operating model in 2024. This along with newly published NHSE guidance for in-patient wards for working age and older people has provided an opportunity for a full review of the culture, systems and process to maximise the patient and staff experience, improve quality and safety and align with community mental health and system partners. The model incorporates four chapters – ‘Purposeful Admission’, ‘Therapeutic Benefit’, ‘Trauma Informed Care’ and ‘Proactive, Safe and Effective Discharge’ which is supported by a detailed implementation plan, which is currently being mobilised across all adult and older adult wards. Community services and Family & Carer engagement is key within the Proactive, Safe and Effective Discharge chapter.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 17 March 2025

    Open published response

  6. Essex

    AI-generated summary

    Margaret Ann PILGRIM · 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

    Margaret Ann Pilgrim died at Princess Alexandra Hospital on 29 June 2023 from congestive cardiac failure and bronchopneumonia, against a background of frailty, after an unwitnessed fall at home caused a fractured clavicle. The fracture was reported on an X-ray during her hospital admission but was not noted on her discharge summary. Concerns included the absence of treatment, pain relief, care-package consideration and fracture-clinic follow-up, and the failure to inform the patient, her family or GP about the fracture.

    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 communicate identified fractures in discharge information

    Wider context from the report

    “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic. ”

    Source location

    Margaret Ann PILGRIM · 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

    Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.

    Verbatim wording from the response

    “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

    Source location

    Response from Princess Alexandra Hospital
    Page 2 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.

    Verbatim wording from the response

    “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

    Source location

    Response from Princess Alexandra Hospital
    Page 2 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.

    Verbatim wording from the response

    “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

    Source location

    Response from Princess Alexandra Hospital
    Page 2 · response
    Published 14 June 2024

    Open published response

  7. Derby and Derbyshire

    AI-generated summary

    Sobia Tabasim Khan · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete and consider a pre-discharge family assessment

    Wider context from the report

    “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered. ”

    Source location

    Sobia Tabasim Khan · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  8. Teesside and Hartlepool

    AI-generated summary

    Kate Elizabeth O’Donnell · 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

    Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

    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 families with deterioration warning signs and actions at discharge

    Wider context from the report

    “10. The family were not provided with information upon discharge as to what signs to look out for and what steps to take if Kate was to deteriorate. ”

    Source location

    Kate Elizabeth O’Donnell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and provide patients and carers with a postoperative sepsis-awareness information card.

    Verbatim wording from the response

    “A conversation should have taken place to advise Kate’s parents of the signs and symptoms of sepsis however on this occasion this did not happen. One of the actions completed as part of the Serious Incident investigation was to develop a sepsis awareness information card which is now given to patients/carers post operatively.”

    Source location

    Response from South Tees Hospitals
    Page 5 · response
    Published 25 January 2024

    Open published response

  9. Cumbria

    AI-generated summary

    Brenda SHIELDS · 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

    Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.

    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 involve family or carers in discharge processes

    Wider context from the report

    “(3) I refer you to the PFD report I issued referring to Charlotte Grace on 29/10/19. Assurances were given in response to that report which again focused on discharge without family/carer involvement which is surely paramount. I note actions mentioned in the incident report in this case but am still concerned that similar events may occur in future. ”

    Source location

    Brenda SHIELDS · 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 involve family in discharge processes

    Wider context from the report

    “(1) Brenda was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after Brenda's death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made. ”

    Source location

    Brenda SHIELDS · 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

    Monitor caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.

    Verbatim wording from the response

    “Actions/Recommendations:”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 4 · response
    Published 13 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.

    Verbatim wording from the response

    “Carer leads continue to roll out carer awareness training. This is at 80% across the service currently. A further 8 staff have had Carer Awareness and Getting To Know You training over the past 4 months. Carer leads also offer 1:1 Training for new staff working within CRHT.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 5 · response
    Published 13 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The investigation concluded that identified family-involvement issues were not causative or contributory to the death.

    Verbatim wording from the response

    “We note that the extent to which the issues with family involvement in this case were not explored in evidence due to the absence of any Trust witnesses however, the written evidence from the SI investigation concluded that the findings/learning identified in this investigation were not considered to be causative or contributory to Brenda's death, particularly as carers' views had been sought at a number of points during Brenda's care and treatment and the Getting To Know You documentation had been completed.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
    Page 6 · response
    Published 13 June 2023

    Open published response

  10. North Northumberland and South Northumberland

    AI-generated summary

    Odessa Carey · 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

    Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

    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 coordinate inpatient discharge with family and other agencies

    Wider context from the report

    “3. Inpatient discharge 30 May 2018 The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family, the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge. I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust. ”

    Source location

    Odessa Carey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to hold a multidisciplinary pre-discharge meeting for future planning

    Wider context from the report

    “4. Discharge from the Community Treatment Team on 6 August 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. ”

    Source location

    Odessa Carey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026