9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 4 Insufficient inquiry into the parameters of care provided by private domiciliary carers View source Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments View source Failure to make post-discharge referrals for patients needing district nursing care View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
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Action
Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
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Action
Participate in HUTH’s time-limited task group to explore digital discharge-planning solutions for patients with complex wounds or pressure ulcers.
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AI-generated summary
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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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to City Health Care Partnership CIC; that does not assign responsibility.
PFD Monitor interpretation Insufficient inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report “(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to City Health Care Partnership CIC; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to City Health Care Partnership CIC; that does not assign responsibility.
PFD Monitor interpretation Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report “(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to City Health Care Partnership CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” 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 Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
Verbatim wording from the response “• Internally CHCP services can send SystmOne to SystmOne referrals, (SystmOne is CHCP main Electronic Care Record (ECR) system). CHCP is currently exploring options to enable external SystmOne users to also send SystmOne to SystmOne referrals.” 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 Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
Verbatim wording from the response “• CHCP regularly shares updates in relation to the referral criteria, services offered and how to refer with GPs and other HCP organisations including Secondary Care, and GPs and HCP organisations also have access to the Directory of Services (DoS) via www.directoryofservices.nhs.uk & NHS Service Finder via www.servicefinder.nhs.uk” 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 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 position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Feedback on the concerns cannot be provided because no referral was made to Community Nursing, and the referral hub manages all CHCP referrals.
Verbatim wording from the response “City Health Care Partnership (CHCP) is unable to provide any feedback in relation to the above concerns, as there was no referral made to CHCP Community Nursing by Hull University Teaching Hospital (HUTH) or St Andrew’s Surgery Hull. CHCP has a 24-hour Care Co-ordination Hub, which manages all referrals into CHCP.” Source location Response from City Healthcare Partnership Hull
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations