11 Nov 2019 Antonis Tofali Hannides · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Lack of a formal system for seeing patients who reattend unexpectedly after discharge View source Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance View source Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after discharge View source
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. 4
Action
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
View source
Action
Add a 2020 local audit of documentation for patients who re-attend after discharge.
View source
Action
Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.
View source
Action
Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.
View source See 1 more action
×
AI-generated summary
Antonis Tofali Hannides · 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
Antonis Tofali Hannides died on 29 March 2019 from liver and heart disease after undergoing hernia repair and subsequently reattending hospital with confusion. Concerns included the lack of a formal system for managing unexpected reattendance after discharge, inadequate documentation, and failure to inform his consultant immediately.
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 Spire Bristol Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal system for seeing patients who reattend unexpectedly after discharge
Wider context from the report “No formal system at Spire Bristol for
1) Seeing patients who reattend unexpectedly after discharge;
2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance;
3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after 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 Spire Bristol Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance
Wider context from the report “No formal system at Spire Bristol for
1) Seeing patients who reattend unexpectedly after discharge;
2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance;
3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after 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 Spire Bristol Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after discharge
Wider context from the report “No formal system at Spire Bristol for
1) Seeing patients who reattend unexpectedly after discharge;
2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance;
3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge.
” 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 Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
Verbatim wording from the response “In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannides’ case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients’ consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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 Add a 2020 local audit of documentation for patients who re-attend after discharge.
Verbatim wording from the response “All RMOs practising at Spire are provided with a copy of Spire’s RMO Handbook, and an induction pack (copy enclosed at Appendix F) which outline further the obligations with regard to good medical record keeping and adherence to Spire’s Patient Records policy. Spire Bristol undertake routine audits of record keeping standards at the hospital in keeping with the Spire Patient Records policy. An additional audit has been added to the local 2020 schedule that will focus specifically on the standard of documentation in the medical records where patients have re-attended the hospital following their discharge.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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 Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.
Verbatim wording from the response “Spire Bristol has undertaken a number of local actions to share learning from this case with respect to record keeping practices including:-” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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 Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.
Verbatim wording from the response “As identified above, in light of the concerns raised at the inquest, Spire’s Admission and Discharge policy and RMO Handbook have been updated to remind staff of the requirements and standards of good medical record keeping practices and explicitly how post-discharge enquiries should be recorded. This policy requires that any clinical encounter with the patient must be comprehensively documented in the patient’s records by the clinical staff involved in the patients’ care. In situations where the patient’s notes are not immediately available, for example as a result of any out of hours query (or in Mr Hannides’ case as a result of an un-expected presentation to outpatients), then a temporary set of records will be created by the team involved in the care of the patient, and merged as soon as possible with the original patient records.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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 Existing patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.
Verbatim wording from the response “All nursing and medical staff at Spire Bristol are subject to professional and contractual obligations to maintain good record keeping standards. Those obligations are detailed in Spire’s Patient Records policy (which was in place at the time of Mr Hannides’ care, a copy of which is enclosed at Appendix E) and provides that “an entry should be made in the healthcare record whenever a patient is seen by a clinician or member of staff. All clinicians and healthcare professionals must make clear, accurate and contemporaneous records relating to their patients. The record must contain regular and timely progress notes, observations and consultation reports made by such professionals. In addition to Spire Healthcare’s requirements, clinicians and healthcare professionals may formally be required to do so by their professional regulatory body.”” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
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 Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
Verbatim wording from the response “It is anticipated that some patients who have undergone treatment at a Spire Hospital may contact the Hospital with enquiries about their care after discharge. As such, Spire Healthcare has an Admission and Discharge policy (in place at the time of Mr Hannides’ admission) which outlines a number of key steps that must take place as part of any patients’ discharge planning process, to ensure that patients are supported after they leave hospital and are aware of how to seek advice if they have concerns.” Source location 2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations