PFD report

Dorothy Joan Strickley · Prevention of Future Deaths report

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Issued 31 Oct 2018•Leicester City and South Leicestershire

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
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 raised4

  1. Lack of standard patient discharge information materials
    Part of recurring concern: Unreliable hospital discharge documentationPart of recurring concern: Unreliable hospital discharge processes
  2. Failure of local policy to reflect NICE guidelines in full
  3. Failure to communicate AES discharge instructions and correct use
    Part of recurring concern: Failure to ensure discharge information is accessible and understood by patients and carers
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 standard patient discharge information materials

Wider context from the report

“A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; 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 local policy to reflect NICE guidelines in full

Wider context from the report

“A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”

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 communicate AES discharge instructions and correct use

Wider context from the report

“A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”

Is this part of a recurring concern?

Yes — Failure to ensure discharge information is accessible and understood by patients and carers.

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 provide AES

Wider context from the report

“A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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