Recipient

City Health Care Partnership CIC

First report 9 Mar 2024•Latest report 9 Mar 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Community interest company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from City Health Care Partnership CIC linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Mar2024
East Riding and Hull
Concerns raised4
1. Insufficient inquiry into the parameters of care provided by private domiciliary carers
2. Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
3. Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
1. Failure to make post-discharge referrals for patients needing district nursing care
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
  Stated in progress
2. Action
  Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
  Stated completed
3. Action
  Participate in HUTH’s time-limited task group to explore digital discharge-planning solutions for patients with complex wounds or pressure ulcers.
  Stated in progress
Respondent positions 1
1. Position
  Feedback on the concerns cannot be provided because no referral was made to Community Nursing, and the referral hub manages all CHCP referrals.
  Unable to act
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.

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. 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
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
Page 2 · response
Published 14 May 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
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
Page 2 · response
Published 14 May 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
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
Page 3 · response
Published 14 May 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
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
Page 1 · response
Published 14 May 2024
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Insufficient inquiry into the parameters of care provided by private domiciliary carers

Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information

Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments

Failure to make post-discharge referrals for patients needing district nursing care

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 3

Respondent positions 1