PFD report

Patrick McGagh · Prevention of Future Deaths report

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Issued 28 Apr 2016•Manchester South

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 prescribed antibiotics are supplied to patients on discharge
    Part of recurring concern: Failure to ensure patients receive the correct prescribed medication at hospital dischargePart of recurring concern: Unreliable hospital discharge processes
  2. Failure to communicate prescribed antibiotic instructions to care staff and the GP
  3. Failure to provide discharge information to the GP
    Part 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.3

  1. Action

    Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 April 2016.
  2. Action

    Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 April 2016.
  3. Action

    Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 April 2016.

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

  1. Position

    Emergency Department attendance notifications are not sent because local GPs agreed they were unnecessary; formal discharge letters follow inpatient stays only.

    Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 prescribed antibiotics are supplied to patients on discharge

Wider context from the report

“On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics. ”

Is this part of a recurring concern?

Yes — Failure to ensure patients receive the correct prescribed medication at hospital discharge; Unreliable hospital discharge processes.

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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 prescribed antibiotic instructions to care staff and the GP

Wider context from the report

“On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics. ”

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 provide discharge information to the GP

Wider context from the report

“On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics. ”

Is this part of a recurring concern?

Yes — 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

Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.

Verbatim wording from the response

“It is documented within the clinical records that Mr McGagh’s carer was advised regarding using a scrotal support and also to monitor for any skin changes and for Mr McGagh to return to hospital urgently if any concerns or his symptoms deteriorate. It is not explicit within the records if the carer in attendance was advised regarding the antibiotics. We agree apologise for this omission, all clinical ED staff have been reminded of the importance of supplying verbal and written instruction as required and this interaction must then be documented in the clinical health records.”

Source location

2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016

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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

Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.

Verbatim wording from the response

“Actions taken:”

Source location

2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016

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

Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.

Verbatim wording from the response

“To support ongoing improvements a regular audit program within the ED to monitor compliance with the policy and documentation has been commenced. Any individual staff identified that are not adhering to the required processes will be managed accordingly.”

Source location

2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 3 · response
Published 28 April 2016

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

Emergency Department attendance notifications are not sent because local GPs agreed they were unnecessary; formal discharge letters follow inpatient stays only.

Verbatim wording from the response

“The Trust does not send notification of attendance to the Emergency Department. This decision was made following consultation with local GP’s, where it was agreed that the ED would no longer issue a notification of attendance on discharge from the ED. Formal discharge letters are produced only following an in-patient stay.”

Source location

2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 2 · response
Published 28 April 2016

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.1

  1. 1

    Reiterate to clinical staff across the organisation the importance of comprehensively documenting discussions with patients, families and carers about treatment and management plans.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 April 2016.

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

Reiterate to clinical staff across the organisation the importance of comprehensively documenting discussions with patients, families and carers about treatment and management plans.

Verbatim wording from the response

“The Trust accepts that Mr McGagh should have been provided with antibiotics prior to his discharge along with a copy of the prescription for his GP. This should have also been clearly discussed with the carer who accompanied Mr McGagh when he attended the department. ████████ has highlighted this to the staff within both ED and CDU. The Trust has also reiterated the importance of comprehensive documentation relating to any discussions had with patient, families and carers regarding treatment and management plans to all clinical staff across the organisation.”

Source location

2016-0171-Response-by-University-Hospital-of-South-Manchester
Page 3 · response
Published 28 April 2016

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