PFD report

Ronald Alfred KELLY · Prevention of Future Deaths report

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Issued 15 Nov 2022•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.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 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. Lack of automatic follow-up for patients discharged home who may need support and care
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
  2. Failure to action appropriate referrals for district nurse visits and assessments
    Part of recurring concern: Unreliable referrals to district nursing services
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

    Review the referral process with staff to identify learning.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2022.
  2. Action

    Amend the Standard Operating Procedure to require tighter follow-up when additional referral information is requested.

    Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 November 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The hospital identified nothing it would do differently in similar circumstances.

    Stated by Milton Keynes University Hospital NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.

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 automatic follow-up for patients discharged home who may need support and care

Wider context from the report

“1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping. 2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first”. The GP forwarded the referral but nothing was actioned. 3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge.

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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 action appropriate referrals for district nurse visits and assessments

Wider context from the report

“1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping. 2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first”. The GP forwarded the referral but nothing was actioned. 3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up. ”

Is this part of a recurring concern?

Yes — Unreliable referrals to district nursing services.

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

Review the referral process with staff to identify learning.

Verbatim wording from the response

“Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 21 November 2022

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

Amend the Standard Operating Procedure to require tighter follow-up when additional referral information is requested.

Verbatim wording from the response

“Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 21 November 2022

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 identified nothing it would do differently in similar circumstances.

Verbatim wording from the response

“While it is impossible not to be affected by the circumstances of Mr Kelly’s death over two weeks later, we have not identified anything that we would seek to do differently in similar circumstances. An elderly gentleman received prompt surgical treatment and his discharge needs were subsequently explored with him and his family by”

Source location

Response from Milton Keynes University Hospital
Page 2 · response
Published 21 November 2022

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 patient did not refuse to wait for care; he was assessed as not requiring a care package.

Verbatim wording from the response

“Mr Kelly was judged to have mental capacity throughout his admission (from providing informed consent for surgical intervention, through to discharge planning). His self-autonomy was respected in line with his mental capacity. Importantly, Mr Kelly did not ‘refuse to wait over the weekend for a care package’: he was not judged to require a care package, nor did he or his partner seek one.”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 21 November 2022

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

Hospital discharge procedures functioned well and were considered an adequate response in this case.

Verbatim wording from the response

“I am conscious that discharge from hospital can be a challenging area, with widespread concern nationally around the availability of domiciliary support and funding of the same. On this occasion, I consider that hospital procedures functioned well and could not reasonably have foreseen subsequent events. It is unfortunate that a Regulation 28 Report was felt to be the appropriate route for us to share this information.”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 21 November 2022

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

MKUH was responsible for the inpatient discharge process because CNWL received no referral and was not involved in the inpatient care.

Verbatim wording from the response

“In response to your first point, we did not receive a referral for Mr Kelly either before or at the point of discharge and were not involved in his care whilst he was an inpatient at MKUH. We note that MKUH have provided a full response in relation to the discharge process, which they kindly shared with us.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 21 November 2022

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

    Continue collaborating with MKUH to improve the inpatient-to-community interface and community care.

    Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2022.

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

  1. 1

    The partner's later fall and subsequent events could not reasonably have been predicted or averted by the hospital.

    Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 collaborating with MKUH to improve the inpatient-to-community interface and community care.

Verbatim wording from the response

“We continue to work closely with MKUH to discuss the inpatient-to-community interface to improve the patient journey, avoid prolonged admissions and enhance the care provided in the community.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 21 November 2022

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 partner's later fall and subsequent events could not reasonably have been predicted or averted by the hospital.

Verbatim wording from the response

“From the information that we have subsequently received, it seems that Mr Kelly’s partner having a fall four days after his discharge may have been a key event: this could not have been predicted or averted by the hospital. The medical information that we hold at the hospital, in the round, did not point to significant psychiatric illness: the only pertinent entry was made in the Emergency Department some months prior where there is passing reference to Mr Kelly having started an anti-depressant in the community.”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 21 November 2022

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