PFD report

Kathleen McGeary · Prevention of Future Deaths report

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Issued 26 Feb 2019•Nottinghamshire

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
10

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 raised10

  1. Failure to fully and properly assess vulnerable patients before discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to properly diagnose patients before discharge
  3. Failure to provide an adequate discharge summary
    Part of recurring concern: Unreliable hospital discharge documentationPart 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

    Replace the Symphony-Medisec link with a Medisec Viewer app that launches with Symphony and communicate its required use to all staff.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  2. Action

    Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. Action

    Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    A CDU consultant made the discharge decision and identified the patient as medically fit for discharge, subject to specified conditions.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes 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 fully and properly assess vulnerable patients before discharge

Wider context from the report

“1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before 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 properly diagnose patients before discharge

Wider context from the report

“1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before discharge. ”

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 provide an adequate discharge summary

Wider context from the report

“3. The electronic discharge summary was inadequate and no paper discharge summary was produced. No explanation was given for this omission. ”

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 to fully and properly investigate patients before discharge

Wider context from the report

“1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before 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 provide prescribed antibiotics at discharge

Wider context from the report

“4. Mrs McGeary left hospital by hospital arranged transport without the antibiotics she had been prescribed for a suspected UTI. No explanation was given for this failing. ”

Is this part of a recurring concern?

Yes — Failure to ensure patients receive the correct prescribed medication at hospital discharge; Failure to provide timely antibiotic treatment for suspected or confirmed infection; 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 clear communication between clinicians and nursing staff

Wider context from the report

“2. No clinician took clear responsibility for discharging decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff.

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 assign clear responsibility for discharge decision making

Wider context from the report

“2. No clinician took clear responsibility for discharging decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care; 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 properly treat patients before discharge

Wider context from the report

“1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before discharge. ”

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 accurately record the identity of the discharging clinician

Wider context from the report

“2. No clinician took clear responsibility for discharging decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear. ”

Is this part of a recurring concern?

Yes — Failure to accurately record the identities of clinicians involved in patient care; 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 address identified clinical and discharge failings through an effective plan

Wider context from the report

“5. At Inquest there appeared a culture of acceptance of the above failings and omissions without any corresponding will or effective plan to address them. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

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

Replace the Symphony-Medisec link with a Medisec Viewer app that launches with Symphony and communicate its required use to all staff.

Verbatim wording from the response

“I understand that during the inquest it was noted that a review of the past medical history from available hospital electronic notes (Medisec letter) was not undertaken which led to the ED team not being aware of her hyperparathyroidism. I would respond by saying that while, as heard in evidence, the Locum Doctor did not have access to Medisec, the Division have investigated this and found that the link between Symphony the system in ED and Medisec occasionally can be temperamental although all locums are provided with access to the Medisec system. On March 26 the current link button was removed from the Symphony system and replaced by a Medisec Viewer app that boots at the time Symphony is activated and is available for all to view and so far we have not experienced any problems with this following the update.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 3 · response
Published 9 June 2019

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

Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.

Verbatim wording from the response

“I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 5 · response
Published 9 June 2019

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

Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.

Verbatim wording from the response

“I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 5 · response
Published 9 June 2019

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

Implement a CDU pathway document to support communication between the main hospital department and CDU on admission.

Verbatim wording from the response

“the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 5 · response
Published 9 June 2019

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

Implement a CDU standard operating procedure defining responsibility across the patient pathway.

Verbatim wording from the response

“We have developed a new CDU (Clinical Decision Unit) standard operating procedure, which I attach, where it makes clear where responsibility lies for various aspects of”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 4 · response
Published 9 June 2019

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 developing an electronic CDU discharge summary and put it in place within three months.

Verbatim wording from the response

“The Division will continue work on an electronic CDU discharge summary to further enhance the discharge process and aims to have this in place within the next 3 months.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 6 · response
Published 9 June 2019

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

A CDU consultant made the discharge decision and identified the patient as medically fit for discharge, subject to specified conditions.

Verbatim wording from the response

“The decision to discharge the patient was made by ████████ CDU Consultant on the ward rounds in the morning who clearly identified that the deceased was medically fit for discharge pending the outcome of the urine dipstick but required a RAPTS assessment. I am led to understand that should the RAPTS team at this stage have had any concerns they would have raised this with staff in ED and not continued with the discharge. I am advised that the team clearly stated that they had no concerns on this occasion. I am also advised by ████████ Patient Safety Lead who attended the Inquest that while the Care Home Manager said that the deceased “looked poorly when she arrived on an ambulance trolley and not in a wheelchair” she was not immediately worried and was happy to accept Mrs McGeary for observation for 24 hours.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 4 · response
Published 9 June 2019

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 received a thorough, appropriate emergency-department assessment for a condition usually managed in primary care.

Verbatim wording from the response

““I have reviewed the available online records for Mrs McGeary. I have not seen the paper notes. From the documentation available she appears to have presented with classical symptoms of lower urinary tract infection associated with delirium. I note a urine dipstick was negative but in the context of symptoms and the fever it will still be reasonable to treat as such as urinary symptoms are more strongly associated with UTI than is a dipstick. There were no features to suggest sepsis and examination from other sources of infection was carried out well. She has a documented normal neurological examination. She was not on any medication that was documented that would increase her risk of falling.”

Source location

2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Page 2 · response
Published 9 June 2019

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