St George's, Epsom and St Helier Hospital Group

Health and care · NHS provider group

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First report 17 Apr 2024•Latest report 17 Apr 2024

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from St George's, Epsom and St Helier Hospital Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Mr Timothy Charles Clayton · 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 Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.

    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 St George's, Epsom and St Helier Hospital Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure a care plan is in place before discharge

    Wider context from the report

    “2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him. Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity. ”
    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 St George's, Epsom and St Helier Hospital Group; that does not assign responsibility.

    PFD Monitor interpretation

    Rushed and uninformed decision making

    Wider context from the report

    “3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making. ”
    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 St George's, Epsom and St Helier Hospital Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide requisite information before relying on decision-making capacity

    Wider context from the report

    “2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him. Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity. ”
    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 St George's, Epsom and St Helier Hospital Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure an adequately assessed discharge planning policy

    Wider context from the report

    “1. The policy in relation to discharge planning remains under review, including how families are to be involved, so it has not been possible to assess the adequacy of the new policy. ”
    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 St George's, Epsom and St Helier Hospital Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to protect properly considered discharge planning from bed-space pressure

    Wider context from the report

    “3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making. ”
    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

Data last updated 7 September 2026