PFD report

Margaret Mary Dempsie · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 24 Oct 2016•Leicester City and South Leicestershire

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to ensure accurate and complete discharge information is communicated to primary care teams
    Part of recurring concern: Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPsPart 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.12

  1. Action

    Increase the frequency of discharge-letter audits for each monthly QMG cycle.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 October 2016.
  2. Action

    Strengthen the Letters Policy to clarify discharge-letter procedures and senior medical oversight.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 October 2016.
  3. Action

    Discuss the case with the consultant involved to encourage reflective learning.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 October 2016.

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

  1. Position

    Responsibility for commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 accurate and complete discharge information is communicated to primary care teams

Wider context from the report

“The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dempsie was not surprised and admitted in the inquest that the Discharge Letters for patients were being completed with mistakes by the Junior Doctors, that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts. He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes being made in the care of vulnerable patients newly discharged from hospital. ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; 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

Increase the frequency of discharge-letter audits for each monthly QMG cycle.

Verbatim wording from the response

“1. The frequency of internal audits for discharge letters will be increased for each QMG every month with immediate effect and our Head of Outcomes and Effectiveness will lead on this.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Strengthen the Letters Policy to clarify discharge-letter procedures and senior medical oversight.

Verbatim wording from the response

“5. Our Head of Outcomes and Effectiveness will strengthen our “Letters Policy” to ensure that there is clarity concerning the process for discharge letters and the importance of senior medical oversight. This should go to the Policy and Guideline Committee Meeting in January 2017.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 3 · response
Published 24 October 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

Discuss the case with the consultant involved to encourage reflective learning.

Verbatim wording from the response

“4. Our Medical Director will ensure that this case is discussed with the Consultant involved before the end of December 2016 to encourage reflective learning. ████████ has met with the junior doctor who wrote the discharge”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Use a standardised discharge-letter template covering admission reasons and discharge diagnoses.

Verbatim wording from the response

“Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Extend GP feedback collection, review findings, discuss necessary actions, report to the Executive Quality Board, and repeat the audit at intervals.

Verbatim wording from the response

“2. Our Chief Medical Information Officer and Head of Services for GP’s will encourage GP’s to provide individualised and patient specific feedback concerning poor discharge letters throughout December 2016 to assess the level of inaccuracies and perception of poor Discharge letters. Our Chief Medical Information Officer will then review any feedback and discuss necessary actions with the doctors involved and the GP dependant upon the findings. He will report on this matter to the Executive Quality Board in March 2017. Our Head of Services for GP’s will promote the opportunities to feedback errors on discharge letters directly to her in the December GP Newsletter. This extended audit will then be repeated at regular intervals, depending on the findings.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Provide junior doctors with e-learning reinforcing accurate information in discharge letters to GPs.

Verbatim wording from the response

“Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Request GP feedback and conduct regular audits of discharge-letter information quality.

Verbatim wording from the response

“In addition, the Trust has for some time requested individualised feedback from GP’s regarding any poor or inaccurate information received from the Trust and undertakes regular audits to provide assurance on the quality of the information provided in Discharge Letters. These audits show an improvement in the quality of the information that we provide to GP’s.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Report monthly discharge-letter audit results to the CCGs’ Contract team for formal oversight.

Verbatim wording from the response

“• UHL undertakes an audit of a sample of discharge letters on a monthly basis, assessing their content and timeliness, with feedback directly to the clinician concerned. The trust reports that they have seen an improvement in both the quality and the accuracy of letters since this started. This monthly audit will continue, and the results will now be reported into the CCGs Contract team for formal overview.”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 1 · response
Published 24 October 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

Continue joint work through the LLR-wide discharge group to address IT barriers to electronic transfer of discharge letters to primary care.

Verbatim wording from the response

“This CCG and our two commissioning partners in Leicestershire and Rutland recognise that the provision of accurate and timely discharge information is a prerequisite for safe and high quality patient care. We have been working together with University Hospitals of Leicester (UHL) to address this and have taken a number of concrete actions:-”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 1 · response
Published 24 October 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

Develop a process for obtaining timely GP feedback on inaccurate discharge letters and supporting rapid correction and clinician learning.

Verbatim wording from the response

“• Getting accurate feedback from GPs whenever there is a problem with Discharge letters is a key part of improving performance. We are currently in discussion with UHL and our GP Colleagues about how this can best be done, probably through a dedicated email contact point. The intention is to get feedback within 24 to 36 hours of receipt of the letter, with rapid contact with the relevant junior doctor both to increase their learning but also to ensure the provision of a corrected an accurate discharge letter where necessary. We are exploring the feasibility of this over the coming weeks.”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 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

Include a discharge-letter quality indicator in the 2017–2018 UHL contract and formally monitor and report it, with corrective-action discussions if improvements are not sustained.

Verbatim wording from the response

“• To ensure there is an ongoing focus on the quality of Discharge letters, the 2017 / 2018 contract with UHL will include a quality indicator within the contract which will be formally monitored and reported to the contract team. This will include discussions around corrective action should the necessary improvements not be sustained. The contracts are due to be agreed by the 23rd of December 2016.”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 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

Include in the junior doctors’ induction programme an item emphasising accurate, timely information for primary care.

Verbatim wording from the response

“• The CCGs are currently in discussion with UHL about the content of their junior doctors Induction programme. We will ensure that an item is included within this programme which highlights the importance of getting accurate information out to primary care colleagues as soon as possible to ensure the appropriate delivery of care to patients.”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 2 · response
Published 24 October 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

Responsibility for commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.

Verbatim wording from the response

“I have reviewed your report in detail and I have identified that the Leicester City Clinical Commissioning Group (“CCG”) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. I have therefore asked the CCG to respond and provide assurance regarding actions they have taken in order to mitigate the risk identified within your report. A copy of their response is enclosed with this letter.”

Source location

2016-0374-Response-by-NHS-England
Page 1 · response
Published 24 October 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.2

  1. 1

    Meet monthly to triangulate GP concern themes and inform Trust-wide patient-safety actions.

    Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 October 2016.
  2. 2

    Disseminate learning from the Regulation 28 Report through the Clinical Quality Review group for joint discussion and consideration of further actions.

    Stated by NHS Leicester City Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 24 October 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

Meet monthly to triangulate GP concern themes and inform Trust-wide patient-safety actions.

Verbatim wording from the response

“Approximately 500 GP concerns per year come through the Patient Safety team and these are themed and discussed at the Clinical Quality Review Group. The Senior Patient Safety Manager and the Head of Services for GPs now meet monthly to triangulate GP concern themes to monitor these and inform required actions at Trust wide level.”

Source location

2016-0374-Response-by-University-of-Leicester-NHS-Trust
Page 2 · response
Published 24 October 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

Disseminate learning from the Regulation 28 Report through the Clinical Quality Review group for joint discussion and consideration of further actions.

Verbatim wording from the response

“• To ensure that learning from this case is disseminated across the trust, the Regulation 28 Report was included as an agenda item at the November Clinical Quality Review group to enable further joint discussion between the trust and the CCG and to consider any”

Source location

2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
Page 1 · response
Published 24 October 2016

Open published response
Back to top

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