PFD report

Thomas George Jordan · Prevention of Future Deaths report

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Issued 10 Aug 2016•West Yorkshire Eastern

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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

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 raised4

  1. Breakdown in hospital-to-prison discharge communication
    Part of recurring concern: Unreliable hospital discharge processesPart of recurring concern: Unreliable transfer of hospital discharge information to prison healthcare
  2. Failure to discontinue medication when directed by hospital clinicians
    Part of recurring concern: Unsafe medication administration
  3. Delayed availability of discharge correspondence to prison healthcare staff
    Part of recurring concern: Unreliable transfer of hospital discharge information to prison healthcare
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

Breakdown in hospital-to-prison discharge communication

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes; Unreliable transfer of hospital discharge information to prison healthcare.

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 discontinue medication when directed by hospital clinicians

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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

Delayed availability of discharge correspondence to prison healthcare staff

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of hospital discharge information to prison healthcare.

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 by prison healthcare staff to review discharge correspondence

Wider context from the report

“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of hospital discharge information to prison healthcare.

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