PFD report

John Andrews · Prevention of Future Deaths report

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Issued 3 Oct 2014•Milton Keynes

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
2

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

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Concerns raised2

  1. Failure to ensure appropriate care is in place at home before discharge
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residentsPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to advise family members of discharge
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisionsPart 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.

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

Failure to ensure appropriate care is in place at home before discharge

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr Andrews was admitted to Milton Keynes Hospital on 31st March 2014 following a fall. (2) Following detailed discussion with ████████ Mr Andrews was discharged from hospital. (3) Mr Andrews was insistent that he wanted to be discharged. (4) ████████ agreed reluctantly, but decided that a discharge would be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital. (5) Upon discharge the plan agreed with ████████ was to implement a care package to assist Mr Andrews at home. (6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance. (7) Formal care arrangements were not arranged until 2-3 days later (Monday). It was too late, as Mr Andrews had fallen when home alone on the first day and was found on the floor by his son, who happened to phone his father, to be told he was at home. (8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home to meet their needs. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents; Unreliable hospital discharge 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 advise family members of discharge

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr Andrews was admitted to Milton Keynes Hospital on 31st March 2014 following a fall. (2) Following detailed discussion with ████████ Mr Andrews was discharged from hospital. (3) Mr Andrews was insistent that he wanted to be discharged. (4) ████████ agreed reluctantly, but decided that a discharge would be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital. (5) Upon discharge the plan agreed with ████████ was to implement a care package to assist Mr Andrews at home. (6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance. (7) Formal care arrangements were not arranged until 2-3 days later (Monday). It was too late, as Mr Andrews had fallen when home alone on the first day and was found on the floor by his son, who happened to phone his father, to be told he was at home. (8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home to meet their needs. ”

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