PFD report

Janet Irene SPENCER · Prevention of Future Deaths report

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Issued 4 Oct 2023•Nottinghamshire

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
1

Of 1 recipient

Stated actions
5

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 ensure all involved have the information required to contribute effectively to the transfer process
    Part of recurring concern: Unreliable healthcare patient transfer processes
  2. Failure to ensure smooth transitions between care facilities during discharge or transfer
    Part of recurring concern: Unreliable healthcare patient transfer processes
  3. Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities
    Part of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable hospital discharge processes
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.2

  1. Action

    Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.

    Stated by Nottinghamshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  2. Action

    Hold weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.

    Stated by Nottinghamshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.

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 all involved have the information required to contribute effectively to the transfer process

Wider context from the report

“2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 smooth transitions between care facilities during discharge or transfer

Wider context from the report

“2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities

Wider context from the report

“1. The systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes; Unreliable hospital discharge processes.

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

Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.

Verbatim wording from the response

“11. The LA recognises that improvements have been required in the clear and accurate sharing of up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s situation. To ensure that the risk of any future breakdown in communication is mitigated, a new process and referral / assessment form has been implemented for all people moving into Assessment Flat accommodation. This process is for hospital and community admissions into”

Source location

Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023

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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 weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.

Verbatim wording from the response

“9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective discussions of hospital discharges that have gone well or where improvements are required.”

Source location

Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023

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.3

  1. 1

    Hold weekly Local Authority Discharge to Assessment Team Manager meetings to review practice and share improvements across the service.

    Stated by Nottinghamshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  2. 2

    Conduct weekly multidisciplinary workshops to review discharge pathways, Transfer of Care Hubs and team working practices.

    Stated by Nottinghamshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  3. 3

    Use an implemented shared dataset and dashboard to track hospital admissions and discharge pathways for safe, timely support.

    Stated by Nottinghamshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2023.

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 weekly Local Authority Discharge to Assessment Team Manager meetings to review practice and share improvements across the service.

Verbatim wording from the response

“12. There are also weekly meetings for the Discharge to Assessment Team Managers from the Local Authority where practice is reviewed, and improvements discussed and shared across the service.”

Source location

Response from Nottinghamshire County Council
Page 3 · response
Published 29 December 2023

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 weekly multidisciplinary workshops to review discharge pathways, Transfer of Care Hubs and team working practices.

Verbatim wording from the response

“8. To ensure continued quality assurance and service improvements there are weekly Multi-Disciplinary Workshops as part of the Integrated Care System Discharge to Assess Planning and Service Provisions. This includes a regular review of Transfer of Care Hubs and Multi-Disciplinary Team working practices. Each month there is a focussed workshop on each Pathway 1-3 and then a more strategic workshop as part of this agreed work plan for the Integrated Care System. These workshops include senior operational and strategic representatives from all key partner agencies and is key to partnership working and collaborative culture to improving hospital discharge for people and their carers/families.”

Source location

Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023

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

Use an implemented shared dataset and dashboard to track hospital admissions and discharge pathways for safe, timely support.

Verbatim wording from the response

“10. Another key improvement for Hospital Discharge planning across the Integrated Care System been the implementation of a shared dataset which tracks people through their hospital admission and pathway out of hospital. This dataset and dashboard is used by NHS and LA partners to ensure that all people leaving hospital are supported to do so in as timely and safe a manner as possible.”

Source location

Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023

Open published response
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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