PFD report

Linda Hudson · Prevention of Future Deaths report

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Issued 24 Sep 2013•County Durham and Darlington

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
4

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 raised4

  1. Delay in scheduling post-discharge nursing follow-up
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
  2. Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide
    Part of recurring concern: Failure to ensure patients receive the correct prescribed medication at hospital discharge
  3. Failure to communicate the discharge medication safety arrangement to the consultant psychiatrist
    Part of recurring concern: Unreliable communication of discharge medication information to care staff
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

Delay in scheduling post-discharge nursing follow-up

Wider context from the report

“(3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday. The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though she was unable to say whether this might have made any difference in all the circumstances. ”

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 an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide

Wider context from the report

“(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this. ”

Is this part of a recurring concern?

Yes — Failure to ensure patients receive the correct prescribed medication at hospital 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 communicate the discharge medication safety arrangement to the consultant psychiatrist

Wider context from the report

“(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this. ”

Is this part of a recurring concern?

Yes — Unreliable communication of discharge medication information to care staff.

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 family members of discharge where family support is relevant to safety

Wider context from the report

“(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions; Unreliable hospital discharge processes.

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