PFD report

Antonis Tofali Hannides · Prevention of Future Deaths report

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Issued 11 Nov 2019•Avon

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. Lack of a formal system for seeing patients who reattend unexpectedly after discharge
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Unreliable hospital discharge processes
  2. Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to ensure immediate informing of consultants about patients who reattend unexpectedly after discharge
    Part of recurring concern: Unreliable consultant review of patients unexpectedly returning after discharge
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.4

  1. Action

    Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.

    Stated by Spire Bristol HospitalStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
  2. Action

    Add a 2020 local audit of documentation for patients who re-attend after discharge.

    Stated by Spire Bristol HospitalStated plannedThe respondent said that this action was planned when they made their response on 27 December 2019.
  3. Action

    Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.

    Stated by Spire Bristol HospitalStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.

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

  1. Position

    Existing patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.

    Stated by Spire Bristol HospitalExisting 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

Lack of a formal system for seeing patients who reattend unexpectedly after discharge

Wider context from the report

“No formal system at Spire Bristol for 1) Seeing patients who reattend unexpectedly after discharge; 2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance; 3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after 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

Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance

Wider context from the report

“No formal system at Spire Bristol for 1) Seeing patients who reattend unexpectedly after discharge; 2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance; 3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 immediate informing of consultants about patients who reattend unexpectedly after discharge

Wider context from the report

“No formal system at Spire Bristol for 1) Seeing patients who reattend unexpectedly after discharge; 2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance; 3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge. ”

Is this part of a recurring concern?

Yes — Unreliable consultant review of patients unexpectedly returning after discharge.

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

Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.

Verbatim wording from the response

“In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannides’ case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients’ consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented.”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 2 · response
Published 27 December 2019

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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

Add a 2020 local audit of documentation for patients who re-attend after discharge.

Verbatim wording from the response

“All RMOs practising at Spire are provided with a copy of Spire’s RMO Handbook, and an induction pack (copy enclosed at Appendix F) which outline further the obligations with regard to good medical record keeping and adherence to Spire’s Patient Records policy. Spire Bristol undertake routine audits of record keeping standards at the hospital in keeping with the Spire Patient Records policy. An additional audit has been added to the local 2020 schedule that will focus specifically on the standard of documentation in the medical records where patients have re-attended the hospital following their discharge.”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 3 · response
Published 27 December 2019

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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

Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.

Verbatim wording from the response

“Spire Bristol has undertaken a number of local actions to share learning from this case with respect to record keeping practices including:-”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 4 · response
Published 27 December 2019

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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

Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.

Verbatim wording from the response

“As identified above, in light of the concerns raised at the inquest, Spire’s Admission and Discharge policy and RMO Handbook have been updated to remind staff of the requirements and standards of good medical record keeping practices and explicitly how post-discharge enquiries should be recorded. This policy requires that any clinical encounter with the patient must be comprehensively documented in the patient’s records by the clinical staff involved in the patients’ care. In situations where the patient’s notes are not immediately available, for example as a result of any out of hours query (or in Mr Hannides’ case as a result of an un-expected presentation to outpatients), then a temporary set of records will be created by the team involved in the care of the patient, and merged as soon as possible with the original patient records.”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 4 · response
Published 27 December 2019

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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 patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.

Verbatim wording from the response

“All nursing and medical staff at Spire Bristol are subject to professional and contractual obligations to maintain good record keeping standards. Those obligations are detailed in Spire’s Patient Records policy (which was in place at the time of Mr Hannides’ care, a copy of which is enclosed at Appendix E) and provides that “an entry should be made in the healthcare record whenever a patient is seen by a clinician or member of staff. All clinicians and healthcare professionals must make clear, accurate and contemporaneous records relating to their patients. The record must contain regular and timely progress notes, observations and consultation reports made by such professionals. In addition to Spire Healthcare’s requirements, clinicians and healthcare professionals may formally be required to do so by their professional regulatory body.””

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 3 · response
Published 27 December 2019

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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 admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.

Verbatim wording from the response

“It is anticipated that some patients who have undergone treatment at a Spire Hospital may contact the Hospital with enquiries about their care after discharge. As such, Spire Healthcare has an Admission and Discharge policy (in place at the time of Mr Hannides’ admission) which outlines a number of key steps that must take place as part of any patients’ discharge planning process, to ensure that patients are supported after they leave hospital and are aware of how to seek advice if they have concerns.”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 1 · response
Published 27 December 2019

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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

    Disseminate learning from the case to RMOs across the network through a clinical update.

    Stated by Spire Bristol HospitalStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.

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

Disseminate learning from the case to RMOs across the network through a clinical update.

Verbatim wording from the response

“2. Been working together with its corporate provider of RMOs, NES Healthcare, on the dissemination of the learning from the sad events following Mr Hannides’ death. NES have provided all of their RMOs with a copy of “how to be an excellent RMO” on induction (copy enclosed at Appendix C). In addition to this the learnings from this case have been provided to all RMOs, across the Spire network, via a clinical update issued by NES on 5th December 2019 (copy enclosed at Appendix D). The update identified learning points including that:-”

Source location

2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 2 · response
Published 27 December 2019

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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