PFD report

Thomas George Jordan · Prevention of Future Deaths report

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Issued 10 Aug 2016•West Yorkshire Eastern

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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. Unavailability of discharge correspondence to prison healthcare staff
    Part of recurring concern: Unreliable transfer of hospital discharge information to prison healthcare
  2. Failure to review discharge correspondence by prison healthcare staff
    Part of recurring concern: Unreliable transfer of hospital discharge information to prison healthcare
  3. Breakdown in communication between hospital and prison at discharge
    Part of recurring concern: Unreliable multi-agency communication proceduresPart of recurring concern: Unreliable transfer of hospital discharge information to prison healthcare
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.1

  1. Action

    Create an electronic pathway to share hospital discharge summaries with HMP Leeds.

    Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 10 August 2016.

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

Unavailability of discharge correspondence to prison healthcare staff

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of hospital discharge information to prison healthcare.

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 review discharge correspondence by prison healthcare staff

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of hospital discharge information to prison healthcare.

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

Breakdown in communication between hospital and prison at discharge

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures; Unreliable transfer of hospital discharge information to prison healthcare.

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 discontinue prescribed medication when requested by hospital clinicians

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”

Is this part of a recurring concern?

Yes — Unreliable implementation of medication changes; Unsafe medication administration.

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

Create an electronic pathway to share hospital discharge summaries with HMP Leeds.

Verbatim wording from the response

“Further to that correspondence, the Head of Healthcare at HMP Leeds has discussed the above with the Clinical Director for Urgent Care at Leeds Teaching Hospital. The Director has agreed that an electronic summary can be issued with all patients who transfer back to HMP Leeds following discharge from a hospital admission. The Hospital currently send an electronic summary to the registered GP and the process for sending the same to the prison can be incorporated within their system. IT personnel from both the Hospital and Care UK will create a pathway that ensures all summaries are appropriately shared. In the meantime, the Director will ensure that written summaries are provided in a sealed envelope for all hospital discharges and these will accompany the patient back to the prison.”

Source location

Response from Care UK
Page 1 · response
Published 10 August 2016

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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