29 Feb 2016 Susan Beverley George · Prevention of Future Deaths report Manchester (North)
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Concerns raised 11 Failure to involve the patient’s Primary/Associate Nurse in discharge View source Failure to review discharge decisions after material changes in patient presentation View source Inadequacy of the discharge policy View source Poor nursing advocacy for patients View source Absence of protocol or guidance for inpatient contact with emergency services View source Disjointed and uncoordinated discharge processes View source Poor nursing record keeping View source Failure to follow the discharge policy View source Unprofessional staff attitudes towards patients and care provision View source Unavailability of an inpatient Clinical Psychologist service View source Staff unawareness of how to support patients seeking a second medical opinion View source See 8 more concerns
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Susan Beverley George · 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
Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.
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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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the patient’s Primary/Associate Nurse in discharge
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse .
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to review discharge decisions after material changes in patient presentation
Wider context from the report “1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Poor nursing advocacy for patients
Wider context from the report “7. Poor advocacy on the part of the nursing staff whose decisions appear to have been clouded by the rigidity of the medical decision to discharge.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Absence of protocol or guidance for inpatient contact with emergency services
Wider context from the report “5. There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment/management.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Disjointed and uncoordinated discharge processes
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Poor nursing record keeping
Wider context from the report “4. Poor record keeping, predominantly on the part of the nursing staff.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Unprofessional staff attitudes towards patients and care provision
Wider context from the report “6. Unprofessional staff attitudes towards patient/care provision – two qualified nurses involved in Susan’s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator. Prevailing attitudes such as this, particularly towards vulnerable adult, puts care standards at risk.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an inpatient Clinical Psychologist service
Wider context from the report “9. There is no inpatient Clinical Psychologist service available within Pennine Care . This is the second (possibly third) PFD Form on the same issue. The Trust maintains that this is as a result of commissioning issues. Without inpatient clinical psychology, there is a marked service gap that puts patients such as Susan at risk.
” 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 NHS Heywood, Middleton and Rochdale Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Staff unawareness of how to support patients seeking a second medical opinion
Wider context from the report “8. Staff were unaware of how to support and advise patients on the issue of obtaining a second medical opinion where the patient disagrees with the first doctor’s decision (in this case, to proceed to discharge).
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations