PFD report

Mrs Georgina Lewis · Prevention of Future Deaths report

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Issued 22 Dec 2016•Gwent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to put discharge plans and follow-up support in place
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
  2. Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to reliably notify primary care of changes affecting patient care
  3. Failure to notify or consult family members before discharge decisions
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisions
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to put discharge plans and follow-up support in place

Wider context from the report

“(2) Following the decision no discharge plan or follow up support was put in place. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge

Wider context from the report

“(3) There was no contemporaneous notification to her GP of the discharge or the assessment leading to discharge, in fact the GP had still not received notification by the time of discovery of Mrs Lewis body ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to reliably notify primary care of changes affecting patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to notify or consult family members before discharge decisions

Wider context from the report

“(1) The decision to discharge was made without notification to or consultation with any family member. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026