PFD report

Clive Edward Rivers · Prevention of Future Deaths report

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Issued 10 Jun 2021•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.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
1

Described in 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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Report evidence summary

Concerns raised3

  1. Failure of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline
    Part of recurring concern: Unreliable hospital discharge processes
  2. Delays in discharge planning and Right to Reside assessment
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to provide Covid-19 vaccination to eligible inpatients
    Part of recurring concern: Failure to reliably provide recommended vaccinations to eligible people
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Local organisations decide whether and where to offer hospital inpatients Covid-19 vaccination, within the JCVI’s prioritisation advice.

    Stated by Department of Health and Social CareRedirects 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 of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline

Wider context from the report

“3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19. ”

Is this part of a recurring concern?

Yes — 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

Delays in discharge planning and Right to Reside assessment

Wider context from the report

“2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19. ”

Is this part of a recurring concern?

Yes — 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

Failure to provide Covid-19 vaccination to eligible inpatients

Wider context from the report

“1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients. Therefore, Mr Rivers was not vaccinated. ”

Is this part of a recurring concern?

Yes — Failure to reliably provide recommended vaccinations to eligible people.

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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

Local organisations decide whether and where to offer hospital inpatients Covid-19 vaccination, within the JCVI’s prioritisation advice.

Verbatim wording from the response

“Anyone in hospital and falling within the JCVI’s recommended groupings being invited for vaccination, would be eligible for the vaccine, subject to a clinical assessment of suitability on a case by case basis and local operational policies. While there is no national guidance preventing hospitals from vaccinating hospital inpatients, operational decisions on who to offer a vaccine to, and in what settings, are made locally, and in the context of the JCVI’s advice.”

Source location

2021-0199-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 2 · response
Published 14 June 2021

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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

    Share the report with the Care Quality Commission and Healthcare Safety Investigation Branch to support patient-safety risk monitoring.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.

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 report with the Care Quality Commission and Healthcare Safety Investigation Branch to support patient-safety risk monitoring.

Verbatim wording from the response

“Finally, you may wish to note that my officials have shared your report with the Care Quality Commission, the independent regulator for quality, and with the Healthcare Safety Investigation Branch (HSIB) to support its intelligence monitoring of patient safety risks. The HSIB conducts national patient safety investigations where certain criteria are met.”

Source location

2021-0199-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 3 · response
Published 14 June 2021

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026