PFD report

Annabel Jean Findlay · Prevention of Future Deaths report

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Issued 1 Mar 2023•Inner West 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
6

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 to contact emergency contacts or next of kin before or at discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to arrange follow-up appointments before discharge
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Unreliable arrangement and communication of patient appointments and follow-upPart of recurring concern: Unreliable hospital discharge processesPart of recurring concern: Unreliable tracking and follow-up of outpatient appointments
  3. Failure to contact the patient after discharge
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires itPart 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.6

  1. Action

    Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.

    Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023.
  2. Action

    Remind hospital colleagues to notify next of kin or emergency contacts after self-discharge against medical advice when the patient consents.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
  3. Action

    Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 10 March 2023.

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

  1. Position

    The hospital considers discharge arrangements appropriate because the patient was low risk, had capacity, and withdrew consent to sharing information with family.

    Stated by Priory GroupDisputes 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 to contact emergency contacts or next of kin before or at discharge

Wider context from the report

“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”

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 arrange follow-up appointments before discharge

Wider context from the report

“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable arrangement and communication of patient appointments and follow-up; Unreliable hospital discharge processes; Unreliable tracking and follow-up of outpatient appointments.

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 contact the patient after discharge

Wider context from the report

“Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Failure to reliably telephone patients when follow-up or assessment requires it; 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

Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.

Verbatim wording from the response

“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location

Response from Priory
Page 2 · response
Published 10 March 2023

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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

Remind hospital colleagues to notify next of kin or emergency contacts after self-discharge against medical advice when the patient consents.

Verbatim wording from the response

“However, in the interest of learning, the PHR Hospital Director, ████████, has shared a reminder with hospital colleagues of the requirement to notify the next of kin or emergency contact of a patient, when self-discharge is taken against medical advice, where a patient consents to this information being shared. This was discussed during a Consultants’ meeting held on Thursday 6 April 2023 and during a Clinical Governance meeting held on Thursday 20 April 2023.”

Source location

Response from Priory
Page 1 · response
Published 10 March 2023

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 a further reminder requiring outpatient follow-up appointments to be booked before discharge.

Verbatim wording from the response

“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location

Response from Priory
Page 2 · response
Published 10 March 2023

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

Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.

Verbatim wording from the response

“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location

Response from Priory
Page 2 · response
Published 10 March 2023

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

Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.

Verbatim wording from the response

“This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.”

Source location

Response from Priory
Page 2 · response
Published 10 March 2023

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

Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.

Verbatim wording from the response

“This matter was also identified as an improvement action as part of the internal learning review referenced above. Nursing and medical colleagues at the hospital have since been reminded about the requirement to make telephone contact with a patient 48 hours after discharge (unless the patient has a confirmed community mental health team/crisis recovery home treatment team appointment within 72 hours of discharge). The purpose of the telephone call is to check on the patient’s welfare and respond to any issues identified. We have already audited the provision of post-discharge telephone calls and identified significant progress: we will continue to audit this monthly, until we have three successive months of 100% compliance.”

Source location

Response from Priory
Page 2 · response
Published 10 March 2023

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

The hospital considers discharge arrangements appropriate because the patient was low risk, had capacity, and withdrew consent to sharing information with family.

Verbatim wording from the response

“You have raised a concern that staff did not contact Ms Findlay’s next of kin / emergency contact at the point of her discharge from hospital.”

Source location

Response from Priory
Page 1 · response
Published 10 March 2023

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