PFD report

James Francis Flynn · Prevention of Future Deaths report

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Issued 31 Oct 2016•Milton Keynes

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
0

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. Lack of detailed care plans for patient discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to inform immediate family of patient discharge
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisionsPart of recurring concern: Unreliable hospital discharge processes
  3. Failure to ensure food or essential provisions are available after discharge for patients with diabetes
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residentsPart 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.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 detailed care plans for patient discharge

Wider context from the report

“(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic. (2) Inadequate planning and management of patient discharge will put patients lives at risk. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 inform immediate family of patient discharge

Wider context from the report

“(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic. (2) Inadequate planning and management of patient discharge will put patients lives at risk. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions; Unreliable hospital discharge processes.

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 ensure food or essential provisions are available after discharge for patients with diabetes

Wider context from the report

“(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic. (2) Inadequate planning and management of patient discharge will put patients lives at risk. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents; Unreliable hospital discharge processes.

Open source report
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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