PFD report

Samuel Joseph BROOKES · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 15 Apr 2025•Shropshire, Telford and Wrekin

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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
20

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised4

  1. Lack of documentation or process demonstrating rearrangement of care
  2. Failure to rearrange required care before arranging transportation home
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residents
  3. Failure to ensure access to an alarm pendant or mobile phone for summoning help
    Part of recurring concern: Unreliable access to emergency communication
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Review and update the discharge-planning SOP, including care-agency confirmation, failed-discharge escalation and documentation requirements.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  2. Action

    Communicate pendant-alarm requirements to patient transport providers and establish cross-system governance for transport-related incidents.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  3. Action

    Require discharge checklists containing safety information to accompany patients and inform transport crews about emergency equipment and alarm access.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Some patient transport safety actions fall outside the Trust’s scope.

    Stated by the Dudley Group NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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

Lack of documentation or process demonstrating rearrangement of care

Wider context from the report

“(2) There was no record or documentation or process to show or demonstrate that the care had been rearranged. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 rearrange required care before arranging transportation home

Wider context from the report

“(1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents.

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 ensure access to an alarm pendant or mobile phone for summoning help

Wider context from the report

“(4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help. ”

Is this part of a recurring concern?

Yes — Unreliable access to emergency communication.

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 require notification of safe return to the hospital or care company

Wider context from the report

“(3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. ”

Is this part of a recurring concern?

Yes — Unreliable return-from-hospital arrangements.

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

Review and update the discharge-planning SOP, including care-agency confirmation, failed-discharge escalation and documentation requirements.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: Discharge team to review and up-date the discharge planning Standard operating procedure (SOP) (previously Complex Discharge Operational Policy) to specific requirements of safe discharge.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 10 · response
Published 23 April 2025

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

Communicate pendant-alarm requirements to patient transport providers and establish cross-system governance for transport-related incidents.

Verbatim wording from the response

“Action 4 Recommendation / Area for Improvement Identified: When discharging patients, transport company to be made aware when the patient has pendant alarm and that this must be left within reach when leaving the property.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 7 · response
Published 23 April 2025

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

Require discharge checklists containing safety information to accompany patients and inform transport crews about emergency equipment and alarm access.

Verbatim wording from the response

“Communication to be sent out to all matrons and teams detailing that the nurse discharge checklist is to be printed and handed to transport company and sent with the discharged patient on discharge. Communication to detail that the discharge checklist must include key patient safety details, pendant alarm information, mobility status and to utilise the free text box with any other important information for the transferring crew (to include availability of mobile phone). This communication should include the necessary checks to be completed by transferring crews to ensure patients have necessary equipment in reach to make emergency calls/have access to pendant alarms. | Interim Divisional Chief Nurse - Medicine”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 8 · response
Published 23 April 2025

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

Train discharge-team staff on accurate clinical-record documentation and required care-agency contact details.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: Improve discharge team documentation in clinical record to evidence safe discharge”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 11 · response
Published 23 April 2025

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

Conduct routine spot-check audits of discharge documentation and continue monthly assurance reporting.

Verbatim wording from the response

“Action Agreed: Routine spot check audits to be scheduled and undertaken by Directorate Manager to ensure documentation requirement is evidenced in the clinical record and provide assurance action acknowledged”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 11 · response
Published 23 April 2025

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

Some patient transport safety actions fall outside the Trust’s scope.

Verbatim wording from the response

“Some of the actions identified regarding patient transport, fall out of scope of the Trust. These will be taken forward by our Deputy Chief Operating Officer and Head of Site Operations and discussed with relevant integrated care system partners in relation to contractual obligations for ensuring patients discharged home are safe and have access to the agreed methods of communication e.g. mobile telephone, pendant alarm (should they have or require one).”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 2 · response
Published 23 April 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. 1

    Share safe-discharge SOPs through governance meetings, ward visits and accessible staff guidance.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  2. 2

    Provide regular Care Transfer Hub feedback to the Discharge Improvement Group and Quality Committee for oversight of readmission prevention.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2025.
  3. 3

    Allocate ward-based discharge facilitators across Medicine Division to improve communication with ward teams.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  4. 4

    Establish a Transfer of Care Hub bringing relevant system partners together for coordinated complex discharges.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  5. 5

    Implement a live Power BI report and assign staff responsibility for monitoring daily discharge-checklist completion.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  6. 6

    Hold a Medicine Division reset week to reinforce safe-discharge processes and test improvement-plan measures.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  7. 7

    Add discharge-checklist audits to AMAT and continue divisional oversight with results reported to the Discharge Improvement Group.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  8. 8

    Discuss with the Education Lead the content and benefits of human-factors training for patient-facing discharge staff.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2025.
  9. 9

    Review contracts with system partners and external providers to ensure safe-discharge actions are supported contractually.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2025.
  10. 10

    Increase safeguarding and human-factors training compliance for staff through booked sessions and protected training time.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  11. 11

    Disseminate safe-discharge learning and Regulation 28 findings to staff, clinical colleagues and discharge governance groups.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  12. 12

    Conduct a thematic review of historical discharge-related incidents to identify learning and future priorities.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2025.
  13. 13

    Re-establish the Discharge Improvement Group with multidisciplinary representation, strategic workstreams and defined outcome measures.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  14. 14

    Mandate completion of the discharge checklist for all inpatients through formal staff communication.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.
  15. 15

    Develop and submit a patient-safety bulletin on safe discharge requirements.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2025.

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

Share safe-discharge SOPs through governance meetings, ward visits and accessible staff guidance.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: To ensure that above procedures are shared with the wider team, understood and embedded into practice.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 11 · response
Published 23 April 2025

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

Provide regular Care Transfer Hub feedback to the Discharge Improvement Group and Quality Committee for oversight of readmission prevention.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: prevent unnecessary readmissions”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 9 · response
Published 23 April 2025

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

Allocate ward-based discharge facilitators across Medicine Division to improve communication with ward teams.

Verbatim wording from the response

“Action 2 Recommendation / Area for Improvement Identified: Discharge team to be ward based to support more effective communication between the teams.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 5 · response
Published 23 April 2025

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

Establish a Transfer of Care Hub bringing relevant system partners together for coordinated complex discharges.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: To improve communication between all relevant services including acute, primary care, community services, social care, housing and voluntary to coordinate care and support for patients during and following discharge process to support and”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 8 · response
Published 23 April 2025

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

Implement a live Power BI report and assign staff responsibility for monitoring daily discharge-checklist completion.

Verbatim wording from the response

“Request for immediate Power BI report to be built to evidence daily discharges checklist completion for monitoring.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 6 · response
Published 23 April 2025

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

Hold a Medicine Division reset week to reinforce safe-discharge processes and test improvement-plan measures.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: Teach and model to staff what a good discharge looks like.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 12 · response
Published 23 April 2025

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 discharge-checklist audits to AMAT and continue divisional oversight with results reported to the Discharge Improvement Group.

Verbatim wording from the response

“Audits to be added to AMAT system (Trust Audit and Management Tracking System) to monitor compliance with the completion of all discharge checklists.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 6 · response
Published 23 April 2025

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

Discuss with the Education Lead the content and benefits of human-factors training for patient-facing discharge staff.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: To consider if the introduction of human factors training for Discharge team staff may benefit in decision making”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 14 · response
Published 23 April 2025

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

Review contracts with system partners and external providers to ensure safe-discharge actions are supported contractually.

Verbatim wording from the response

“Action Agreed: Review of current contracts held with system partners and outside providers to ensure actions agreed within Trust can be met through contractual arrangements.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 7 · response
Published 23 April 2025

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

Increase safeguarding and human-factors training compliance for staff through booked sessions and protected training time.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: All staff who have safeguarding training and human factors training as part of their mandatory training requirements should meet Trust compliance targets for such training.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 14 · response
Published 23 April 2025

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

Disseminate safe-discharge learning and Regulation 28 findings to staff, clinical colleagues and discharge governance groups.

Verbatim wording from the response

“Action Agreed: Patient Safety Bulletin to be disseminated across the organisation”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 4 · response
Published 23 April 2025

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

Conduct a thematic review of historical discharge-related incidents to identify learning and future priorities.

Verbatim wording from the response

“In parallel, a thematic review of historical discharge-related incidents is underway to identify key learning points and inform future priorities. The Group comprises of multidisciplinary representation, including colleagues from within the acute trust, our health and social care partners, the local authority, and a representative from our patient community. This collaborative approach is intended to provide confidence that the discharge processes are being strengthened system-wide, with patient safety and continuity of care as central principles.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 2 · response
Published 23 April 2025

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

Re-establish the Discharge Improvement Group with multidisciplinary representation, strategic workstreams and defined outcome measures.

Verbatim wording from the response

“In addition to our improvement plan, the Trust has re-established with a renewed and enhanced focus the Discharge Improvement Group. This Group has strategic organisational objectives focussed not only on increasing the timeliness of patient discharges from the organisation, but more importantly on ensuring that each discharge is carried out with the highest standards of safety and quality. As part of this work, dedicated workstreams have been initiated to support the proactive and coordinated planning of discharges across both simple and complex care pathways. The group have reviewed and agreed clear outcome measures to ensure the impact of actions can be measured, and that they are having a positive impact.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 2 · response
Published 23 April 2025

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

Mandate completion of the discharge checklist for all inpatients through formal staff communication.

Verbatim wording from the response

“Action 3 Recommendation / Area for Improvement Identified: To mandate and monitor the completion of the discharge checklist across the Trust.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 5 · response
Published 23 April 2025

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

Develop and submit a patient-safety bulletin on safe discharge requirements.

Verbatim wording from the response

“Recommendation / Area for Improvement Identified: Disseminate the safety critical learning from the inquest findings highlighting to staff the key requirements of a safe and effective discharge.”

Source location

Response from The Dudley Group NHS Foundation Trust
Page 4 · response
Published 23 April 2025

Open published response
Back to top

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