PFD report

Winnie Harrop · Prevention of Future Deaths report

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Issued 19 Mar 2025•Manchester South

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
2

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 clear cross-sector guidance on when and in what circumstances patients may be returned to care homes
  2. Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs
    Part of recurring concern: Failure to ensure people are placed in care settings suitable for their needsPart of recurring concern: Unreliable hospital discharge processes
  3. Failure of discharge letters to communicate clinically significant sedation and oxygen requirements
    Part of recurring concern: Unreliable documentation and communication of patients’ oxygen requirementsPart 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.1

  1. Action

    Work with NHS England to ensure local systems follow and embed existing hospital discharge guidance.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.

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

  1. Position

    Clear statutory guidance already covers hospital discharge and collaboration with onward care providers, contrary to the concern that guidance is lacking.

    Stated by Department of Health and Social CareDisputes 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

Lack of clear cross-sector guidance on when and in what circumstances patients may be returned to care homes

Wider context from the report

“(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. ”

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

Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs

Wider context from the report

“(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. ”

Is this part of a recurring concern?

Yes — Failure to ensure people are placed in care settings suitable for their needs; 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 of discharge letters to communicate clinically significant sedation and oxygen requirements

Wider context from the report

“(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. ”

Is this part of a recurring concern?

Yes — Unreliable documentation and communication of patients’ oxygen requirements; 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

Work with NHS England to ensure local systems follow and embed existing hospital discharge guidance.

Verbatim wording from the response

“Once again, I would like to offer my sincere condolences to Ms Harrop’s family. This situation is an unacceptable one, and I am truly sorry for the devastating and irreversible consequences this has had. I can assure you that my officials are working with colleagues in NHS England, to ensure this situation is avoided at all costs in the future, and that local systems follow and embed the existing guidance.”

Source location

Response from DHSC
Page 2 · response
Published 26 March 2025

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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

Clear statutory guidance already covers hospital discharge and collaboration with onward care providers, contrary to the concern that guidance is lacking.

Verbatim wording from the response

“Your report raises concerns over a lack of clear health and social care guidance on hospital discharge, specifically under what circumstances it is appropriate to send a patient back to a care home.”

Source location

Response from DHSC
Page 1 · response
Published 26 March 2025

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

Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.

Verbatim wording from the response

“Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.”

Source location

Response from NHSE
Page 1 · response
Published 26 March 2025

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

Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.

Verbatim wording from the response

“Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.”

Source location

Response from NHSE
Page 1 · response
Published 26 March 2025

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

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting safety learning across national and regional NHS teams.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    NHS England is responsible for ensuring trusts follow statutory discharge guidance and is preparing the substantive response to the concerns.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting safety learning across national and regional NHS teams.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Winnie, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHSE
Page 2 · response
Published 26 March 2025

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

NHS England is responsible for ensuring trusts follow statutory discharge guidance and is preparing the substantive response to the concerns.

Verbatim wording from the response

“Evidently, in Ms Harrop’s case, there was a new requirement for oxygen, and a need for a reassessment of her discharge plan. It is the responsibility of NHS England to engage with trusts to ensure that the statutory discharge guidance is followed. As such, in preparing this response, my officials have made enquiries with NHS England to ensure that we adequately and fully address your concerns. I have been made aware that they are preparing their own response to this PFD report, which will incorporate regional input to provide additional context and explanation for this very sad case.”

Source location

Response from DHSC
Page 1 · response
Published 26 March 2025

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