PFD report

Jamie Pashley · Prevention of Future Deaths report

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Issued 28 May 2017•Inner South London

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
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
2

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. Failure to make telephone contact between discharge and first appointment review
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires it
  2. Reliance on individuals to proactively manage their rehabilitation after discharge
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
  3. Limited availability of hospital alcohol liaison nurse support
    Part of recurring concern: Unreliable access to appropriate addiction supportPart of recurring concern: Unreliable alcohol detoxification care and support
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

    Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
  2. Action

    Consider a business case to increase the Alcohol Liaison team and improve patient access to liaison staff.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Expanding telephone follow-up would require additional funding for the Trust’s alcohol dependency service.

    Stated by King'S College Hospital NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 make telephone contact between discharge and first appointment review

Wider context from the report

“Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Failure to reliably telephone patients when follow-up or assessment requires it.

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

Reliance on individuals to proactively manage their rehabilitation after discharge

Wider context from the report

“Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

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

Limited availability of hospital alcohol liaison nurse support

Wider context from the report

“Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

Is this part of a recurring concern?

Yes — Unreliable access to appropriate addiction support; Unreliable alcohol detoxification care and support.

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 fixed post-discharge appointments after detoxification

Wider context from the report

“Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable arrangement and communication of patient appointments and follow-up.

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

Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.

Verbatim wording from the response

“The Trust’s view is that a more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient’s GP may be a more effective approach. There is currently a trial underway in which King’s College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards.”

Source location

2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Consider a business case to increase the Alcohol Liaison team and improve patient access to liaison staff.

Verbatim wording from the response

“The Trust acknowledges that there is demand for an increased team so that patients can access staff that they worked with whilst an in-patient. Approach approaches have been made to local CCGs and charities without success to date, and so the Trust is considering a business case to increase the Alcohol Liaison team. The benefits to”

Source location

2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Expanding telephone follow-up would require additional funding for the Trust’s alcohol dependency service.

Verbatim wording from the response

“As is the case with the provision of fixed appointments, the Trust recognises that making telephone contact in this interim period may be beneficial for some alcohol dependency patients. However, it is again unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently.”

Source location

2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Existing motivational models and pre-discharge links to appropriate third-sector services are preferred over fixed hospital follow-up appointments.

Verbatim wording from the response

“Alcohol dependency patients have notoriously very high DNA rates. As a result, providing fixed follow-up appointments for this category of patients after detoxification as an in-patient and signposting would likely generate a high level of wasted appointments. This is why it is common practice within the NHS to instead use motivational models and to ensure patients as far as practicable are linked in with appropriate third-sector services prior to discharge rather than providing further hospital appointments.”

Source location

2017-0172-Response-by-Kings-College-Hospital-NHS-Trust
Page 1 · response
Published 4 August 2017

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