PFD report

John Howe · Prevention of Future Deaths report

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Issued 25 Jun 2024•Manchester South

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
3

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 changes in discharge timings to the ambulance service
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to discharge patients within the required timing when they are unable to manage independently at home
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to ensure factual accuracy in Serious Incident Review reports
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management 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.6

  1. Action

    Share the draft Out of Hours Discharge Avoidance SOP with Wythenshawe Hospital and North Manchester General Hospital teams.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  2. Action

    Develop and progress the Out of Hours Discharge Avoidance SOP through MRI governance ratification for operational use.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  3. Action

    Implement processes preventing investigations from depending on a single person.

    Stated by Manchester City CouncilStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.

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

  1. Position

    Existing ward contact before evening discharges will safeguard patients until the hospital’s discharge policy is received.

    Stated by East Midlands Ambulance Service NHS TrustExisting 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

Failure to communicate changes in discharge timings to the ambulance service

Wider context from the report

“(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings. ”

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 discharge patients within the required timing when they are unable to manage independently at home

Wider context from the report

“(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings. ”

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 ensure factual accuracy in Serious Incident Review reports

Wider context from the report

“(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management 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

Delays in completing Serious Incident Reviews

Wider context from the report

“(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews. ”

Is this part of a recurring concern?

Yes — Unreliable formal safety-incident management 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

Share the draft Out of Hours Discharge Avoidance SOP with Wythenshawe Hospital and North Manchester General Hospital teams.

Verbatim wording from the response

“MFT comprises of several adult hospital sites, and ambulance transport services are utilized across the organisation. The draft SOP has therefore also been shared with the teams at Wythenshawe Hospital and North Manchester General Hospital who have confirmed their intention to take it through their relevant governance structures to ratify and implement. I anticipate that this will prevent inconsistencies in discharge practices across the organisation, which could have led to challenges for external providers.”

Source location

Response from MFT
Page 2 · response
Published 27 June 2024

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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

Develop and progress the Out of Hours Discharge Avoidance SOP through MRI governance ratification for operational use.

Verbatim wording from the response

“The MRI team have confirmed that a formal process for managing delayed discharges has now been developed via an “Out of Hours Discharge Avoidance” Standard Operating Procedure (SOP), which will be utilised as part of the operational application of the MFT Discharge Policy. Whilst this SOP is still in draft, it is due to be presented for ratification at the MRI Quality and Safety Committee on Tuesday 13th August 2024. For completeness a copy of the draft SOP has been enclosed within this correspondence.”

Source location

Response from MFT
Page 2 · response
Published 27 June 2024

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

Implement processes preventing investigations from depending on a single person.

Verbatim wording from the response

“I recognise the delay in completing the initial SIR due to myself not being in work, and as such we have set up a system, as a service, to ensure all investigations are completed in a timely manner going forward. In reviewing the systems it is essential we are not dependent on a single person within the service and, as such, we have put in place processes to ensure that this does not happen again.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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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

Establish a service-wide system to ensure investigations are completed in a timely manner.

Verbatim wording from the response

“I recognise the delay in completing the initial SIR due to myself not being in work, and as such we have set up a system, as a service, to ensure all investigations are completed in a timely manner going forward. In reviewing the systems it is essential we are not dependent on a single person within the service and, as such, we have put in place processes to ensure that this does not happen again.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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

Share consultation agencies’ information for review and accuracy checking before finalising Serious Incident Reviews.

Verbatim wording from the response

“We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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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

Correct inaccuracies in the Serious Incident Review and reshare the amended report with relevant safeguarding teams.

Verbatim wording from the response

“I am extremely saddened by the events of the Mr John Howe’s death and, following your report, we have amended the inaccuracies in the report and reshared the Serious Incident Review (SIR) with Derbyshire Safeguarding Adults Board. I have also rehashed the amended SIR with Manchester Foundation Trust Safeguarding Team.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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

Existing ward contact before evening discharges will safeguard patients until the hospital’s discharge policy is received.

Verbatim wording from the response

“During the Inquest, it was ascertained that discharges for patients on the wards at Manchester Royal Infirmary now have a cut off time at 21.00 hours for discharge from a hospital ward. At the time of the Inquest EMAS was not aware of this. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue to act as a safeguard to patients until the policy is received from Manchester Royal Infirmary.”

Source location

Response from EMAS
Page 2 · response
Published 27 June 2024

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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

The second concern relates to Manchester City Council, so MFT will not provide a response.

Verbatim wording from the response

“MFT was notified of the second concern outlined within the Regulation 28 report issued following the inquest, we understand that this relates to Manchester City Council and therefore no response is required from MFT on this matter.”

Source location

Response from MFT
Page 1 · response
Published 27 June 2024

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.3

  1. 1

    Continue contacting hospital wards before evening discharges to confirm that transporting patients remains appropriate.

    Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  2. 2

    Review processes for out-of-area hospital discharges involving safeguarding concerns.

    Stated by Manchester City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  3. 3

    Engage relevant partners in Serious Incident Reviews and share outcomes and recommendations with them.

    Stated by Manchester City CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Further safeguarding review screening is assigned to the appropriate Safeguarding Board, with a recommendation for a Safeguarding Adults Review where needed.

    Stated by Manchester City CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 contacting hospital wards before evening discharges to confirm that transporting patients remains appropriate.

Verbatim wording from the response

“During the Inquest, it was ascertained that discharges for patients on the wards at Manchester Royal Infirmary now have a cut off time at 21.00 hours for discharge from a hospital ward. At the time of the Inquest EMAS was not aware of this. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue to act as a safeguard to patients until the policy is received from Manchester Royal Infirmary.”

Source location

Response from EMAS
Page 2 · response
Published 27 June 2024

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 processes for out-of-area hospital discharges involving safeguarding concerns.

Verbatim wording from the response

“We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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

Engage relevant partners in Serious Incident Reviews and share outcomes and recommendations with them.

Verbatim wording from the response

“We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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

Further safeguarding review screening is assigned to the appropriate Safeguarding Board, with a recommendation for a Safeguarding Adults Review where needed.

Verbatim wording from the response

“Where there is still a need for further engagement with other partners to review where the areas of learning which the serious harm experienced by an adult at risk of abuse or neglect could have been prevented, it will be sent to the appropriate Safeguarding Board for screening with a recommendation for a Safeguarding Adults Review.”

Source location

Response from MCC
Page 1 · response
Published 27 June 2024

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