PFD report

Andrea Jane Thirkell · Prevention of Future Deaths report

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Issued 30 Mar 2015•County Durham and Darlington

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised2

  1. Failure to provide structured monitoring or formal observations during delayed discharge
    Part of recurring concern: Unreliable patient observation arrangements
  2. Lack of formal policy or written guidance for safe late-at-night discharge decisions
    Part 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.

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.2

  1. Action

    Amend the Trust’s Going Home Policy to specify Emergency Department discharge procedures, including discharges after 22:00.

    Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 March 2015.
  2. Action

    Implement discharge-time observations, apply the Early Warning Score protocol when necessary, and record the results in Symphony, with routine audit of record completeness.

    Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2015.

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 structured monitoring or formal observations during delayed discharge

Wider context from the report

“(1) Although considered to be medically fit for discharge at 19.25 hours she did not leave the department until 23.03 and during that time she was not subject to any structured form of monitoring or observation although nursing staff may have seen her during that time. Evidence was given that since this incident staff have been reminded that patients should be subject to formal observations if there is a delay in discharge. Although I was told this I am unclear as to whether there is a formal trust policy in place in this regard. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Lack of formal policy or written guidance for safe late-at-night discharge decisions

Wider context from the report

“(2) The deceased did not leave the department until 23.03. Evidence was given that it is common for patients to be discharged late on a night either home or to a care home knowing that there is likely to be nursing care available. The evidence I heard was that there was no formal trust policy or written guidance with regard to the issue of late at night discharge and what other factors need to be taken account of in considering whether it is safe to discharge a patient at such time and in what circumstances. The evidence was that each senior doctor will apply his or her own medical discretion and combined with the pressures on a busy department I am concerned that this could lead to inconsistent or potentially erroneous decisions being made. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge 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

Amend the Trust’s Going Home Policy to specify Emergency Department discharge procedures, including discharges after 22:00.

Verbatim wording from the response

“This change in practice will be implemented immediately. Amendments have also been made to the Trusts ‘Going Home Policy’ (POL/NG/0005A), to reflect the discharge procedure from the Emergency Department including discharges after 22.00 hours. This was discussed and approved at the Trust’s Executive Clinical Lead meeting on 21st May 2015 and will be discussed at the Quality and Healthcare Governance meeting in June 2015. The change in practice will be implemented immediately and audited as part of the routine Symphony records audit in which three sets of notes are audited daily for completeness.”

Source location

Thirkell-R2015-0124
Page 2 · response
Published 30 March 2015

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 discharge-time observations, apply the Early Warning Score protocol when necessary, and record the results in Symphony, with routine audit of record completeness.

Verbatim wording from the response

“The issue you have raised was discussed at the Emergency Department senior staff meeting at the University Hospital North Durham which convened on 23 April 2015 and was subsequently discussed and agreed by the Emergency Department at Darlington Memorial Hospital. The consensus of opinion was that at the time of leaving the department it would have been sensible for a member of the team to have undertaken a set of observations on the patient, to act upon these if necessary as per the Early Warning Score (EWS) protocol and then to record these in the allotted field on Symphony (the Emergency Department electronic notes system). In addition there is also a field in Symphony, under the transport Data Entry Protocol (DEP), which the team member is able to utilise to record the name of the person to whom the patient is returning.”

Source location

Thirkell-R2015-0124
Page 2 · response
Published 30 March 2015

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.1

  1. 1

    Record the responsible adult receiving a discharged patient in Symphony’s transport data field to evidence responsibility for the patient’s safety and wellbeing.

    Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2015.

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

Record the responsible adult receiving a discharged patient in Symphony’s transport data field to evidence responsibility for the patient’s safety and wellbeing.

Verbatim wording from the response

“The issue you have raised was discussed at the Emergency Department senior staff meeting at the University Hospital North Durham which convened on 23 April 2015 and was subsequently discussed and agreed by the Emergency Department at Darlington Memorial Hospital. The consensus of opinion was that at the time of leaving the department it would have been sensible for a member of the team to have undertaken a set of observations on the patient, to act upon these if necessary as per the Early Warning Score (EWS) protocol and then to record these in the allotted field on Symphony (the Emergency Department electronic notes system). In addition there is also a field in Symphony, under the transport Data Entry Protocol (DEP), which the team member is able to utilise to record the name of the person to whom the patient is returning.”

Source location

Thirkell-R2015-0124
Page 2 · response
Published 30 March 2015

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