PFD report

Graham Harold WATTS · Prevention of Future Deaths report

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Issued 3 Apr 2014•Brighton and Hove

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
9

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 communicate discharge information to receiving care providers and family
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to involve families and carers in discharge planning and decisionsPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to ensure patients are medically fit for discharge
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to complete discharge paperwork
    Part of recurring concern: Unreliable hospital discharge documentationPart 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.9

  1. Action

    Start and evaluate a one-year multidisciplinary pilot for consistent management of frail elderly patients across three wards, with learning intended for wider Trust implementation.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2014.
  2. Action

    Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2014.
  3. Action

    Add a social worker to the ward’s daily multidisciplinary Board Round to support discharge planning.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.

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

  1. Position

    The discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.

    Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 discharge information to receiving care providers and family

Wider context from the report

“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to involve families and carers in discharge planning and decisions; 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 ensure patients are medically fit for discharge

Wider context from the report

“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

Is this part of a recurring concern?

Yes — 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 complete discharge paperwork

Wider context from the report

“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; 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 maintain an ongoing discharge process

Wider context from the report

“(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

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

Start and evaluate a one-year multidisciplinary pilot for consistent management of frail elderly patients across three wards, with learning intended for wider Trust implementation.

Verbatim wording from the response

“The Trust is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, led by an individual from the discipline most relevant to the individual patient’s circumstances, in preparation for their discharge. Subject to successful recruitment, it is anticipated that the pilot will start in July 2014 on three wards. This pilot will be evaluated throughout the year as well as at its conclusion so that the learning from it can be extended throughout the Trust for the benefit of frail elderly patients.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.

Verbatim wording from the response

“The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

Add a social worker to the ward’s daily multidisciplinary Board Round to support discharge planning.

Verbatim wording from the response

“In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014

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

Adjust Board Round whiteboard information to include discharge-planning details.

Verbatim wording from the response

“In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014

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

Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.

Verbatim wording from the response

“The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014

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 monthly snapshot audits of ward medical records to monitor discharge-documentation standards.

Verbatim wording from the response

“Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.

Verbatim wording from the response

“The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

Review the forms used for discharge planning.

Verbatim wording from the response

“The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

Increase junior nurses’ shadowing of senior colleagues to strengthen discharge decision-making and communication skills.

Verbatim wording from the response

“The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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

The discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.

Verbatim wording from the response

“The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 3 April 2014

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

The patient was medically ready for discharge, with satisfactory observations and no reason to regard him as medically unready.

Verbatim wording from the response

“There is increasing recognition among Trust staff that the nationally widely used term “Medically Fit for Discharge” (often abbreviated to MFFD) can be very misleading. There is a growing ground-swell of opinion that it would be less open to misinterpretation if the phrase “Medically Ready for Discharge” (MRFD) or some similar form of words were adopted. Mr Watts was already for discharge in as much as that he no longer required active medical treatment in an acute hospital at the time of his discharge. His last set of clinical observations taken during the afternoon immediately before he left the hospital were entirely satisfactory, with a National Early Warning Score of zero: there was therefore no reason to identify him as medically unready for discharge.”

Source location

2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 3 April 2014

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