PFD report

Kevin John McDonald · Prevention of Future Deaths report

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Issued 16 May 2019•Worcestershire

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 retain discharge documentation
    Part of recurring concern: Unreliable hospital discharge documentationPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to provide clear discharge follow-up advice and guidance
    Part of recurring concern: Failure to ensure discharge information is accessible and understood by patients and carersPart of recurring concern: Unreliable hospital discharge documentation
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 retain discharge documentation

Wider context from the report

“(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this. ”

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 provide clear discharge follow-up advice and guidance

Wider context from the report

“(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients. The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain. It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this. ”

Is this part of a recurring concern?

Yes — Failure to ensure discharge information is accessible and understood by patients and carers; Unreliable hospital discharge documentation.

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