Stephen Mark AMER · Prevention of Future Deaths report

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Issued 25 Jul 2014•Hertfordshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
0

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

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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Concerns raised0

    Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

    1. Hertfordshire County Council

      Develop and introduce a consent form enabling patient information to be shared with social care services.

    2. Hertfordshire County Council

      Share the coroner’s conclusions with local hospital trusts to encourage sufficient time for face-to-face discharge discussions with relatives and carers.

    3. Hertfordshire County Council

      Share revised carer-assessment and discharge requirements with health partners and request equivalent practice for relevant hospital discharges.

    4. Hertfordshire County Council

      Share the coroner’s observations and recommendations with other local authorities through adult social services practice-development meetings.

    5. Hertfordshire County Council

      Issue a practice instruction requiring separate carer assessments covering decision impacts, required support and contingency plans.

    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 introduce a consent form enabling patient information to be shared with social care services.

    Verbatim wording from the response

    “During the inquest, ████████ ████████ referred to a new protocol which was being developed with our health partners. We entirely agree with your recommendation that consent arrangements should be included to allow patient information to be shared with social care services (your first bullet point on page 2 of your letter).”

    Source location

    2014-0344-Response-by-Hertfordshire-County-Council
    Page 1 · response
    Published 25 July 2014

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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

    Share the coroner’s conclusions with local hospital trusts to encourage sufficient time for face-to-face discharge discussions with relatives and carers.

    Verbatim wording from the response

    “The method of communication must indeed be considered carefully (your third recommendation). Whilst carers and relatives may choose not to take up the opportunity of a face to face meeting to discuss discharge arrangements, this remains the preferred and most effective method of communicating care arrangements. This arrangement provides a better opportunity to discuss and clarify every aspect of care and any associated concerns. It is recognised that mounting pressure on NHS hospital beds can result in very limited notice of discharge. We will share your conclusions with local hospital trusts in an effort to ensure that they allow sufficient time to discuss discharges with relatives / carers face to face.”

    Source location

    2014-0344-Response-by-Hertfordshire-County-Council
    Page 2 · response
    Published 25 July 2014

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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

    Share revised carer-assessment and discharge requirements with health partners and request equivalent practice for relevant hospital discharges.

    Verbatim wording from the response

    “The County Council will share this new requirement with health colleagues and request that they follow the same practice when they arrange hospital discharges of vulnerable patients or carers outside of social care referral arrangements.”

    Source location

    2014-0344-Response-by-Hertfordshire-County-Council
    Page 1 · response
    Published 25 July 2014

    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 the coroner’s observations and recommendations with other local authorities through adult social services practice-development meetings.

    Verbatim wording from the response

    “I would like to thank you for your recommendations which we formally accept. We will introduce the revised arrangements outlined above and will share these with our health partners within Hertfordshire. We will also take the opportunity to share your observations and recommendations more widely with other local authorities through the network of practice development meetings organised by the Association of Adult Social Services.”

    Source location

    2014-0344-Response-by-Hertfordshire-County-Council
    Page 2 · response
    Published 25 July 2014

    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

    Issue a practice instruction requiring separate carer assessments covering decision impacts, required support and contingency plans.

    Verbatim wording from the response

    “We also understand that where there is a change of plan, in this case, reflecting the clearly expressed wish of Mrs Amer that she wished to return to her home, that the change of plan is given to the relevant person, in particular the carer. I refer to your second bullet point on page 2 of your letter and in the light of this tragic case, the department has issued a practice instruction to social care staff to create or update a separate carer’s assessment. This must consider the impact of the decision on the carer and set out in detail the support they will require to continue caring if that is their wish. The assessment must also address contingency plans if for any reason they become unable to care for the vulnerable person.”

    Source location

    2014-0344-Response-by-Hertfordshire-County-Council
    Page 1 · response
    Published 25 July 2014

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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