26 Jan 2024 Jeanine Maria HUGGINS · Prevention of Future Deaths report Norfolk
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Concerns raised 2 Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot View source Lack of pre-placement side-room risk assessment of patients’ ability to communicate their needs in an emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jeanine Maria HUGGINS · 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
Jeanine Maria Huggins, who was being treated for diffuse large B-cell lymphoma, was admitted with neutropenic sepsis, dehydration and acute kidney injury and initially showed clinical improvement. She was found not breathing during the night of 9 May 2022 and could not be resuscitated; the inquest concluded that she died from natural causes, with coronary artery atheroma and lymphoma on treatment recorded as the medical cause of death. Concerns included the absence of a formal risk assessment for patients placed in side rooms, including assessment of their ability to use a call bell or suitable alternatives, and failures to escalate raised NEWS scores in accordance with guidance.
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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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot
Wider context from the report “2. There is no formal requirement to ensure that a patient is risk assessed with regard to ability to use a call bell and, if they are unable, to consider suitable alternatives , especially when in a side room and there is no other way to attract staff attention .
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-placement side-room risk assessment of patients’ ability to communicate their needs in an emergency
Wider context from the report “1. There is no requirement for a risk assessment to be carried out before a patient is placed in a side room (other than for risk of falls), so as to identify if they will have any risks and difficulties associated with communicating their needs to staff in an emergency situation .
” Open source report
7 May 2021 John Graham Slope · Prevention of Future Deaths report Norfolk
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Concerns raised 6 Failure to obtain treatment summaries from other hospitals before procedures View source Failure of consent forms and anaesthetic checklists to prompt documentation of tube presence View source Lack of medical-record method for identifying a salivary bypass tube in situ View source Poor-quality pre- and post-operative treatment documentation View source Failure of clinical specialist nurses to escalate patient concerns View source Failure of clinical specialist nurses to document patient concerns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Graham Slope · 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
John Graham Slope underwent treatment including insertion of a salivary bypass tube after developing a fistula following laryngectomy. A tube was later found to be absent, and an abdominal X-ray showed a foreign body in his stomach that was not identified at the time. In August 2020 he was admitted extremely unwell with a perforated small bowel and a foreign body, was too unwell for surgery, and died shortly afterwards. Concerns included poor documentation and the absence of systems to record and identify the tube, as well as failure to document his concerns and obtain a treatment summary from another hospital.
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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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain treatment summaries from other hospitals before procedures
Wider context from the report “That the hospital did not request a summary of Mr Slope’s treatment at a different hospital before commencing the procedures , this could easily be requested via e mail.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of consent forms and anaesthetic checklists to prompt documentation of tube presence
Wider context from the report “That there is nowhere on the consent form or the anaesthetic checklist for the presence of a tube to be asked about and documented . These are basic common-sense measures which should have been in place. Had the absence of the tube been noted when it was only in the stomach it is likely that Mr Slope would not have died months later from a perforated small bowel.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical-record method for identifying a salivary bypass tube in situ
Wider context from the report “That there is no method of noting in the medical records that a salivary bypass tube is in the patient’s body .
That this death happened nearly nine months ago and still there is no method of showing staff in the notes that a patient has this prosthesis and that no thought had been given to this simple measure e.g. a rubber stamp stating patient has a bypass tube in situ to be ticked and signed. The hospital already uses this method for when an intravenous cannulae is inserted and hip prosthesis. This is immediately noticeable and would alert 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality pre- and post-operative treatment documentation
Wider context from the report “That the quality of the documentation pre and post operatively is of poor quality and would not assist other staff to find out what treatment had been given .
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical specialist nurses to escalate patient concerns
Wider context from the report “That the clinical specialist nurses did not contact anyone or document the concerns raised by Mr Slope in March 2020.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical specialist nurses to document patient concerns
Wider context from the report “That the clinical specialist nurses did not contact anyone or document the concerns raised by Mr Slope in March 2020.
” 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 Develop operational workarounds to share and transfer information across regional clinical IT systems.
Verbatim wording from the response “Concerns about the lack of inter-connectivity of IT systems between the Trusts has been discussed at the ENT governance meetings; a risk assessment was completed, added to the NNUH (lead provider) risk register and approved in December 2020. At present, the clinicians do not have access to the relevant IT systems across the region to obtain full information for all patients for which they have clinical responsibilities, whether working from any site or remotely. A system wide approach is required to align the different IT systems, for example e-mail accounts, risk and incident management systems, dictation programmes,” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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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 Progress the approved strategic case for a shared electronic patient record through national regulatory approval toward regional implementation.
Verbatim wording from the response “Longer term, our three hospital (JPUH, QEH, NNUH) electronic records system is now at the strategic outline case stage, which has been approved by all three hospital Trusts and is now with the national regulatory team to approve. This will see, upon implementation, a single patient record known as Electronic Patient Record (EPR), accessible electronically at all sites. The timeline for implementation depends on the pace of regulatory approvals and the governance cycle. The earliest implementation is likely to begin in 2022.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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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 Audit documentation for salivary bypass tubes, including insertion, patient discussion, follow-up presence and procedural records.
Verbatim wording from the response “To better inform our plan for the future, we are also auditing the revised documentation of patients with salivary bypass tubes to include the date of insertion; the point of discussion with the patient regarding the tube being inserted; at follow up whether there is clear evidence of it being in situ; and, a procedural note of it being inserted.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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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 Adapt the ORSOS surgical-notes template to record retained or implanted items and their planned management across surgical specialties.
Verbatim wording from the response “Your suggestion of a rubber stamp on the printed operation note has been given careful consideration. However, on a practical level, it is felt that this may not entirely address this issue given the practices and procedures in place within the hospital. It is common for more than one operation note to be printed for the notes. Also, if a surgeon, anaesthetist or member of theatre staff, is viewing the electronic copy of the note as part of the pre-operative planning or in a MDT, the rubber stamp would not be visible. Therefore, to address this, ████████ has adapted ORSOS (Theatres documentation system) to include in the ‘surgeon’s notes’ area of the template a section for documenting retained/implanted items and another for their planned management.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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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 Implement the regional shared-care record programme by scanning active patient records into the electronic document-management system for provider access.
Verbatim wording from the response “In the meantime, a shared care record programme across the region will provide patient data to each Trust. In essence, active patient records are being scanned onto Electronic Document Management System (EDMS) each time a patient is admitted to hospital or attends a clinic. This will improve the visibility of patient records to all providers in a read-only format and will improve communication about patients such as Mr Slope as it will amalgamate records which previously may have been held in paper format by different teams and avoid messages such as those made by the nurse specialists not being within the records viewed by the Consultant. The target for full implementation is September 2021.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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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 A rubber stamp may not fully address salivary-tube documentation because multiple printed notes and electronic records may not display it.
Verbatim wording from the response “Your suggestion of a rubber stamp on the printed operation note has been given careful consideration. However, on a practical level, it is felt that this may not entirely address this issue given the practices and procedures in place within the hospital. It is common for more than one operation note to be printed for the notes. Also, if a surgeon, anaesthetist or member of theatre staff, is viewing the electronic copy of the note as part of the pre-operative planning or in a MDT, the rubber stamp would not be visible. Therefore, to address this, ████████ has adapted ORSOS (Theatres documentation system) to include in the ‘surgeon’s notes’ area of the template a section for documenting retained/implanted items and another for their planned management.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
Open published response
12 Mar 2015 NICOLA ANNE TWEEDY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to complete documentation forms properly and in a timely manner View source Failure to complete the discharge checklist form View source Failure to ensure the nurse completing discharge notes has seen the patient View source Failure to provide procedure and aftercare leaflets to patients View source Unclear implementation of training and auditing of forms View source Failure to complete thromboprophylaxis risk assessments early enough for proper risk consideration View source Incomplete nursing discharge notes covering required pre-discharge checks View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
NICOLA ANNE TWEEDY · 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
Mrs Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.
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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete documentation forms properly and in a timely manner
Wider context from the report “Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording that this is done. This will only work if forms are properly and timely completed – see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the discharge checklist form
Wider context from the report “The checklist form for completion on discharge was not completed.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the nurse completing discharge notes has seen the patient
Wider context from the report “There was no evidence that the Nurse completing the notes had actually seen Mrs Tweedy prior 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide procedure and aftercare leaflets to patients
Wider context from the report “Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording that this is done. This will only work if forms are properly and timely completed – see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear implementation of training and auditing of forms
Wider context from the report “Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording that this is done. This will only work if forms are properly and timely completed – see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete thromboprophylaxis risk assessments early enough for proper risk consideration
Wider context from the report “The Thromboprophylax Risk Assessment form was not completed at any point throughout Mrs Tweedy’s dealings with the hospital. Had the Risk Assessment been completed this would have flagged up specific risk factors relating to Mrs Tweedy well before the operation. It was noted the Risk Assessment had not been completed following Mrs Tweedy being anaesthetised and this did start discussion between the Consultant Surgeon overseeing the procedure and the Anaesthetist about the risk factors and action to be taken. However, at this stage in the procedure, it did not allow for a full and proper consideration of the relevant information early on when proper thought could have been given to the risks and potential risks.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete nursing discharge notes covering required pre-discharge checks
Wider context from the report “Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged.
” 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 Report thromboprophylaxis audit data at clinical and governance meetings.
Verbatim wording from the response “Our doctors have already started reporting their data at clinical and governance meetings. This is part of the underlying evidence for the revision of national guidance on thromboprophylaxis. The evidence on this is not at all conclusive, however, and other centres may adopt different approaches as they consider appropriate in the circumstances.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Audit documentation forms to verify completion of required leaflet records.
Verbatim wording from the response “It is understood that a “tick box” has now been added to documentation recording that this will work if forms are properly and timely completed. It is understood that a full auditing of forms is now in place, and it is clear how this is being carried out.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Document leaflet provision using a pre-assessment tick box and required staff entries.
Verbatim wording from the response “This has not however documented in the past, we have now required our staff to document that they have given standard information to each patient—in order to avoid excessive paperwork.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
Open published response
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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 Review and audit implementation of the revised thromboprophylaxis practice, including bleeding complications and whether reconsideration is needed.
Verbatim wording from the response “The implementation of this change in clinical practice is being reviewed at all levels. The guidance on thromboprophylaxis is not at all conclusive, however, and other centres may adopt different approaches as they consider appropriate in the circumstances.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Review the day-case discharge process outside the Day Procedure discharge pathway for consistency.
Verbatim wording from the response “Our Action Plan on this case explained that whilst this issue was covered by the existing Day Procedure (DPD) discharge checklist, the process applying to day-case patients outside the DPD was to be reviewed to ensure that this was consistent.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Continue rolling out electronic prescribing to mandate required documentation and collect completion-rate data.
Verbatim wording from the response “We are continuing to roll-out our electronic prescribing system which will automatically mandate and will automatically gather data on completion rates.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 The discharge documentation concern was considered a misinterpretation because nursing evidence indicated the patient had been seen and relevant advice recorded.
Verbatim wording from the response “We believe that this issue must be based on a misinterpretation, as the evidence of the nurse completing the notes had actually seen the patient.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 Although the thromboprophylaxis assessment was undocumented, clinicians exercised professional judgment consistent with national practice and administered heparin.
Verbatim wording from the response “This Consultant Anaesthetist and the Consultant Surgeon have confirmed that a risk assessment for Thromboembolism was not documented. The assessment was not however documented. It was agreed that the patient should be given Heparin and that the Consultant Anaesthetist would be entitled to have an assessment completed. It would have been helpful had the risk assessment form been completed, as this would have avoided subsequent discussion in this case. However in line with most of Heparin in this case was however the UK national practice in centres also represented the professional clinical judgement.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
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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 The existing Day Procedure discharge checklist covered day-case discharge requirements, although the process for cases outside that pathway was reviewed.
Verbatim wording from the response “The full in-patient discharge checklist would not be expected to apply to a day-case patient; however, we wanted to ensure that patients were discussed to ensure patients adequately reflected the need to assess the patient's ability to use before discharge.” Source location 2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
Open published response
27 Oct 2014 JACKSON TERRY SELLERS MITCHELL · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Extravasation of concentrated feeding fluid from low-lying UVCs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
JACKSON TERRY SELLERS MITCHELL · 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
Jackson Terry Sellers Mitchell was born prematurely at 31 weeks and received parenteral nutrition through an umbilical venous catheter. He developed abdominal distension, deteriorated despite treatment and transfer to another hospital, and died on 10 May 2014. The post-mortem attributed his death to intraperitoneal extravasation of parenteral nutrition solution associated with umbilical vein catheterisation; concerns included the catheter's lower position and the need for further investigation into catheter positioning and fluid extravasation.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Extravasation of concentrated feeding fluid from low-lying UVCs
Wider context from the report “The damage found to Jackson's liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it .
Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors.
There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters .
Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC.
” Open source report
5 Aug 2014 JOHN HENRY WILSHER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to communicate concerns about care home adequacy View source Delays in NCC Community Services assessments View source Unavailability of nursing assessment outcomes during community services assessments View source Inaccurate information in NNUH discharge letters View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
JOHN HENRY WILSHER · 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
Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.
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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns about care home adequacy
Wider context from the report “(2) Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November 2013 for assessment and plans were made for discharge to the Care Home. Neither NNUH nor the Care Home were aware concerns had already been raised (prior to a further deterioration in his condition) as to the adequacy of the Care Home to cope with his needs . On Mr Wilsher’s discharge to the Care Home it quickly became apparent they could not cope with his needs.
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in NCC Community Services assessments
Wider context from the report “(3) An assessment was carried out by NCC Community Services on 13 December 2013 by which time Mr Wilsher had been admitted to NNUH and discharged and plans were already in place for his transfer to a nursing home .
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of nursing assessment outcomes during community services assessments
Wider context from the report “(4) The outcome of the Nursing Assessment carried out on 10 December 2013 was not available at the time of the Community Services Assessment .
” 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 Norfolk and Norwich University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate information in NNUH discharge letters
Wider context from the report “(1) The information contained in the NNUH Discharge Letter is inaccurate ;
” 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 Change the training programme supporting use of discharge letter templates.
Verbatim wording from the response “The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:” Source location 2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Open published response
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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 Monitor the changes’ effects and assess whether further steps are needed to support safe transfer between hospital and community.
Verbatim wording from the response “We will continue to monitor the effect of the changes outlined above and whether any further steps are necessary to promote the safe transfer of care between hospital and community.” Source location 2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
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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 Create a bespoke discharge letter template for Older People’s Medicine patients with relevant clinical fields.
Verbatim wording from the response “The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:” Source location 2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
Open published response
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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 Revise clinician prompts for completing discharge letters to ensure inclusion of relevant information.
Verbatim wording from the response “The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:” Source location 2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
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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 Revise the discharge letter template to simplify completion and emphasise critical information.
Verbatim wording from the response “The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more 'rounded' picture of the patient and improved continuity of care. The steps being taken may be summarised as follows:” Source location 2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations