Recurring concern

Failure to reliably notify specialist teams of hospital admissions and discharges

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First reported 4 Sep 2013•Latest report 19 Nov 2025

Definition

What this concern includes

Includes failures of arrangements to identify relevant patients and notify their responsible specialist or community clinical team about hospital admissions, emergency-department presentations or discharges, including notification policy, system access, routing, confirmation and follow-up where these directly support continuity of specialist care.

Not included

  • Excludes generic inter-agency information-sharing failures where hospital admission or discharge notification to a responsible specialist or community team is not the unsafe condition.
  • Excludes notifications to GPs or primary-care practices where no specialist-team notification is involved.
  • Excludes failures in specialist assessment, treatment or follow-up after the team was reliably notified.
  • Excludes general discharge communication, summaries or medication-transfer failures that do not concern notifying the responsible specialist or community team of the admission or discharge.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Great Western Hospital1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Jeesal Akman Care Corporation Limited1
Jeesal Holdings Limited1
Jeesal Residential Care Services Limited1
Mid Yorkshire Teaching NHS Trust1
Norfolk and Norwich University Hospital1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
University Hospitals of Leicester NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Wiltshire and Swindon

    AI-generated summary

    Anna Maria Burns · 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

    Anna Maria Burns was found unresponsive on 12 January 2024 after taking more than her prescribed amounts of medication, including methadone, and was declared deceased that day. The inquest concluded that she died from multidrug toxicity involving methadone, zopiclone and pregabalin, while her intent remained unclear. The principal concern was that the methadone prescribing authority was not informed of her November 2023 opioid overdose and hospital admission, limiting its ability to review overdose risks and prescribing arrangements.

    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 notify methadone prescribing authorities of hospital admissions for opioid overdose

    Wider context from the report

    “(1) The prescribing agency (for methadone) was unaware of the opiate overdose in November 2023 and the resultant hospital admission until the inquest, and after Anna's death. (2) Whilst a discharge summary was properly sent to the (previous) GP, no such notice regarding the opiate overdose was sent to the opiate prescribing authority. (3) Evidence was heard at the inquest that had the prescribing authority known of the opioid overdose in November 2023, they would have reviewed her case and likely would have put in place restrictive prescribing practices (such as lower or single daily doses, possibly supervised). It is also possible that they may have contacted the GP to warn them of the increased risk. Evidence was heard that not knowing of such an admission left the prescribing authority in a position of potentially approving inappropriate prescribing regimes (with risk of overdose in such cases). (4) I did not find that GWH's were in any way obliged to send the discharge summary to the prescribing agency, and neither was such an omission causative or contributory to Anna's death. I did not find the prescribing regime was inappropriate, but it is possible that in other or future cases, a prescribing agency could be unaware that a patient had been treated for overdose at hospital and would therefore be unable to properly review the overdose risks to its patients in an informed way, and that future deaths may occur as a result. (5) It should be considered that notification to relevant parties (especially methadone prescribing authorities) regarding hospital admission for drug overdoses take place in the same manner as GP's highlighting the nature of the admission (i.e. overdose). ”

    Source location

    Anna Maria Burns · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Ethel Mitchell ROBERTSON · 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

    Ethel Mitchell ROBERTSON, who had a long history of depression and anxiety, chronic alcohol consumption and previous intentional drug overdoses, was found deceased at home on 18 February 2024. The inquest concluded that she died from the consequences of an intentional overdose taken to end her life. The report raised concerns that the Older Persons Mental Health Service was not routinely informed when its patients attended or were discharged from an emergency department for physical-health issues, potentially delaying follow-up, risk management and decision-making.

    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 routinely inform OPMH of patients’ emergency department admissions and discharges

    Wider context from the report

    “An Area Matron at the Older People’s Mental Health Service [OPMH] gave evidence that the service is not routinely informed when one of their patients is admitted to or discharged from ED. If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital. However, if the presentation is for something not related to mental health, the OPMH will not be notified as clinicians within the ED do not have access to the computer systems operated by service providers in the community. I am concerned that OPMH will not know if one of their patients has had a physical health crisis which could precipitate a decline in their mental health or has presented with something that those not familiar with the patient might fail to appreciate is linked to their mental health. I am concerned that this will have serious implications for patient safety and could delay appropriate follow-up, risk management and decision-making. It also places an added pressure on those in primary care to have systems in place to alert the community teams when they receive discharge documentation from ED. ”

    Source location

    Ethel Mitchell ROBERTSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Checking every Emergency Department patient for undisclosed mental illness is impractical and disproportionate because of workload, limited clinical indicators and privacy objections.

    Verbatim wording from the response

    “However, to check every patient attending the Emergency Departments for physical health conditions as to whether or not they also have a mental illness is not practical. Some people with mental illness also have objections to their mental health records being shared more widely. Even with connected computer systems, the additional workload of checking every patient to establish whether they have mental health issues is disproportionate to the small number of cases where the mental health conditions are not evident to the clinicians in the Emergency Department.”

    Source location

    Response from Southern Health Foundation Trust
    Page 1 · response
    Published 19 November 2025

    Open published response

  3. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    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 notify the respiratory team of emergency department attendances

    Wider context from the report

    “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. 3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems ”

    Source location

    Ben Buster KING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.

    Verbatim wording from the response

    “That said, the importance of effective communication is clearly recognised and to promote good quality handovers the Respiratory team now hold a daily morning report meeting, attended by all the on-call specialities. At these meetings cases are discussed and referred to other specialities as appropriate.”

    Source location

    2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
    Page 1 · response
    Published 23 July 2021

    Open published response

  4. West Yorkshire Western Division

    AI-generated summary

    Denton Donovan DUHANEY · 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

    Denton Donovan Duhaney was admitted to hospital with physical and mental health concerns and was assessed as being at high risk of further mental health deterioration. He self-discharged without assessment by the hospital’s in-house psychiatric team or notification to the community treatment team, and was found dead at home several days later; the recorded cause of death was hanging (asphyxia), with a conclusion of suicide. The substantive concerns included failures in psychiatric assessment, discharge protocol, communication about the self-discharge, and follow-up arrangements.

    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 notify the intensive home-based treatment team of a patient's self-discharge

    Wider context from the report

    “3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge. ”

    Source location

    Denton Donovan DUHANEY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Mid Yorkshire Hospitals NHS Trust will provide its own response regarding the hospital’s notification of the community team after self-discharge.

    Verbatim wording from the response

    “Points 3 and 4 above have elements that overlap, and we have therefore responded to both below. It is understood that Mid Yorkshire Hospitals NHS Trust will also provide their own response to point 3 as this can be interpreted to apply to both Trusts.”

    Source location

    2021-0200-Response-from-Fieldhead-Hospital_Published
    Page 2 · response
    Published 14 June 2021

    Open published response

  5. Leicester City and South Leicestershire

    AI-generated summary

    Karen Lesley SUTTON · 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

    Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

    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 share hospital admissions with the Immunology team

    Wider context from the report

    “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012. (4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. ”

    Source location

    Karen Lesley SUTTON · 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

    Remind all Consultants of their duty to contact specialist teams when complex patients require care beyond their competence.

    Verbatim wording from the response

    “When Mrs Sutton was admitted the following process was in place and should have been followed. The admitting Consultant should ensure that s/he is aware of the clinical needs of the patient and further ensure that s/he consults appropriately with other clinical specialties where the patient has complex needs which fall outside of that consultant’s competence. As a result of your concerns we have strengthened our current process by undertaking the following actions:”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 1 · response
    Published 4 September 2013

    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

    Make software available to provide daily alerts about previously identified complex patients requiring specialist input after admission.

    Verbatim wording from the response

    “b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the ████████ ████████████████████████████████████████ ████████████████████████████████████████████████████”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 1 · response
    Published 4 September 2013

    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

    Ask every Consultant to identify complex patients in their service for inclusion in the admission alert process.

    Verbatim wording from the response

    “b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the ████████ ████████████████████████████████████████ ████████████████████████████████████████████████████”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 1 · response
    Published 4 September 2013

    Open published response
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Data last updated 7 September 2026