Recipient

Spire Bristol Hospital

First report 11 Nov 2019•Latest report 11 Nov 2019

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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: 3
Stated actions: 5

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

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Spire Bristol Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Nov2019
Avon
Concerns raised3
1. Lack of a formal system for seeing patients who reattend unexpectedly after discharge
2. Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance
3. Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after discharge
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
  Stated completed
2. Action
  Add a 2020 local audit of documentation for patients who re-attend after discharge.
  Stated planned
3. Action
  Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.
  Stated completed
1. Action
  Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.
  Stated completed
Respondent positions 2
1. Position
  Existing patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.
  Existing arrangements considered sufficient
1. Position
  Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
  Existing arrangements considered sufficient
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
Page 2 · response
Published 27 December 2019
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
Page 3 · response
Published 27 December 2019
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
Page 4 · response
Published 27 December 2019
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
Page 4 · response
Published 27 December 2019
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
Page 3 · response
Published 27 December 2019
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
Page 1 · response
Published 27 December 2019
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 raised3

Lack of a formal system for seeing patients who reattend unexpectedly after discharge

Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance

Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after discharge

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 4

Respondent positions 2