Northern Health and Social Care Trust

Health and care · NHS trust

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First report 28 Sep 2017•Latest report 28 Sep 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
2

Described in responses

Concerns and recipient responses

Statements from Northern Health and Social Care Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Conall Patrick Gould · 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

    Conall Patrick Gould died at Queen Elizabeth Hospital in Birmingham on 13 February 2017 after behaving erratically and collapsing; the medical cause of death was recorded as ecstasy use. The report raised concerns that arrangements for his community mental health follow-up appointment after discharge were not communicated to him or his parents, and that the absence of a clear protocol or written confirmation created a risk that follow-up opportunities could be missed.

    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 Northern Health and Social Care Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure that service users and carers receive follow-up appointment details on discharge

    Wider context from the report

    “1. At the time of discharge from Holywell Hospital on the 30th January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2nd February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence of ████████ Consultant Psychiatrist, who saw Conall and his father on the 30th January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another Trust ████████ had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30th January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4. The evidence of ████████ who conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost. ”
    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

    Implement enhanced discharge documentation requiring written follow-up details, contact numbers, and agreed information for patients and carers.

    Verbatim wording from the response

    “The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 day follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge. This protocol also directs that a relative/concerned other, identified by the patient, will also be provided with this written information when consent to do so has been given by the patient.”

    Source location

    Conall-Patrick-Response
    Page 1 · response
    Published 28 September 2017

    Open published response
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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