Recurring concern

Unreliable urgent recall of discharged patients requiring hospital care

First to latest report 19 May 2015 — 17 Jan 2018

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures in dedicated urgent recall arrangements for discharged patients, including recognising the need for recall, initiating and communicating the recall, arranging ambulance or other urgent transport, coordinating the receiving hospital or ward, and confirming that the patient returns for required care.

What is not included
  • Excludes routine post-discharge follow-up, appointment reminders or ordinary missed-contact processes where urgent recall to hospital is not the unsafe condition.
  • Excludes ambulance dispatch, attendance or hospital handover failures occurring after an urgent recall has been correctly initiated, unless they directly impair the recall process.
  • Excludes general discharge-planning, medication, treatment or care-package deficiencies where no failure of urgent recall is identified.
  • Excludes failures to provide hospital care after the recalled patient has safely returned, unless the urgent recall process itself was deficient.

Reports and published responses 2 reports

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

  1. Brighton and Hove

    AI-generated summary

    Barry John TUCKER · 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

    The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of the system for recalling discharged urology patients by ambulance

    Wider context from the report

    “(6) Eastbourne District General Hospital’s system for recalling patients to the Urology ward following discharge, if they need to go in by ambulance, is flawed. ”

    Source location

    Barry John TUCKER · Prevention of Future Deaths report
    Page 2 · 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

    There was no transfer delay caused by ambulance-service communication; extrication difficulties and clinical deterioration caused the on-scene delay.

    Verbatim wording from the response

    “(6) Eastbourne DGH’s system for recalling patients to the Urology Ward following discharge, if they need to go by ambulance, is flawed.”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 6 · response
    Published 8 March 2018

    Open published response

  2. Derby and Derbyshire

    AI-generated summary

    Sheila Johnson · 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

    Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a system for urgent recall of discharged patients with potentially life-threatening conditions

    Wider context from the report

    “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”

    Source location

    Sheila Johnson · 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

    Establish an urgent recall procedure directing staff to contact patients or relatives, then primary-care, community or police services when necessary.

    Verbatim wording from the response

    “The Trust acknowledges your concerns and accepts them in full. The fact that there was no formal system for the urgent recall of patients discharged with potentially life threatening conditions, has been addressed by the Patient Flow Manager.”

    Source location

    2015-0238-Response-by-Tameside-Hospital-NHS-Trust
    Page 4 · response
    Published 19 May 2015

    Open published response

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

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Data last updated 7 September 2026