PFD report

Michael Vukovic · Prevention of Future Deaths report

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Issued 29 Jan 2018•Inner South London

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

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

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

Concerns raised3

  1. Failure of the Home Treatment Team to see referred patients
    Part of recurring concern: Unreliable community Home Treatment Team care pathways
  2. Failure to ensure contact with referred drug and alcohol services
  3. Discharge from hospital without follow-up
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart 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.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The patient was not referred to the Home Treatment Team, so the concern that he was referred but not seen is factually incorrect.

    Stated by Oxleas NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 Home Treatment Team to see referred patients

Wider context from the report

“My specific concerns are as follows: (1) ████████ evidence that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline. (3) The result was that Mr Vukovic was discharged from hospital without follow up. ”

Is this part of a recurring concern?

Yes — Unreliable community Home Treatment Team care pathways.

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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 ensure contact with referred drug and alcohol services

Wider context from the report

“My specific concerns are as follows: (1) ████████ evidence that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline. (3) The result was that Mr Vukovic was discharged from hospital without follow up. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Discharge from hospital without follow-up

Wider context from the report

“My specific concerns are as follows: (1) ████████ evidence that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline. (3) The result was that Mr Vukovic was discharged from hospital without follow up. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable hospital discharge processes.

Open source report

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 patient was not referred to the Home Treatment Team, so the concern that he was referred but not seen is factually incorrect.

Verbatim wording from the response

“(1) Dr Apio’s evidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team.”

Source location

Michael-Vukovic-Response
Page 1 · response
Published 8 June 2018

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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

Discharge without follow-up was considered sufficient because the family knew how to access crisis support if required.

Verbatim wording from the response

“(3) Mr Vukovic was discharged from hospital without follow up.”

Source location

Michael-Vukovic-Response
Page 2 · response
Published 8 June 2018

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

Engagement with external drug and alcohol support services was the individual's responsibility rather than Oxleas' responsibility to secure.

Verbatim wording from the response

“Although Mr Vukovic was on a Greenwich ward, he had a Bexley GP. Lifeline would therefore not have been able to provide support. The support worker form Lifeline who visited Mr Vukovic on the ward provided him with the details of Pier Road. Pier Road is a service external to Oxleas that supports Bexley residents with drug and alcohol issues. The crux is with this and other similar services on the individual to engage.”

Source location

Michael-Vukovic-Response
Page 2 · response
Published 8 June 2018

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