PFD report

Charlotte Grace · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 29 Oct 2019•Cumbria

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to routinely involve agencies receiving discharged patients in the discharge process
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to routinely involve supportive families or friends in the discharge process
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisionsPart 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.5

  1. Action

    Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
  2. Action

    Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.
  3. Action

    Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.

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 routinely involve agencies receiving discharged patients in the discharge process

Wider context from the report

“(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted. 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting. I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process. ”

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 routinely involve supportive families or friends in the discharge process

Wider context from the report

“(1) Lottie was discharged despite there being no input from those to whose care she was being entrusted. 2 years ago I sat on an inquest in Carlisle which found that a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting. I understand this is now less likely to occur in Carlisle and would be generally desirable. I am concerned that agencies to whom a patient is discharged and families or friends [with consent] who will need to be supportive are not routinely involved in the discharge process. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions; 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

Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.

Verbatim wording from the response

“1. A learning review was carried out following the investigation on 16th November 2018 in which it was discussed that attendance of significant clinicians involved with the patient’s care at the time and those responsible for providing future care would be best practice. The learning review suggested that where geographical barriers or workloads prevent face to face attendance at meetings, teleconferencing / videoconferencing could be used as an alternative.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 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

Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.

Verbatim wording from the response

“2. Where geographical restrictions exist, teams utilise phone dial in and will move to Skype facilities within the next 3 months as part of the Trust’s IT mobilisation planning and roll out.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 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

Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.

Verbatim wording from the response

“4. In order to ensure that the relevant teams/services are invited to discharge meetings, this is monitored as per the Trust’s discharge flow chart. This flow chart provides prompts for teams to be invited and indicates that meeting arrangements will be agreed at least 2 days ahead unless urgent. Where attendance is not possible the flow chart states that this should be escalated to team leaders. Although this flow chart was in existence at the time of the incident, it is apparent that it was not being used consistently however, following a safer discharge project staff have been reminded to utilise this. The project includes a commitment to ensure that an agreed follow up is in place within 48 hours of discharge.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 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

Hold weekly interface meetings to discuss complex cases and escalate discharge-meeting non-attendance to clinical leads and, where persistent, the Associate Director.

Verbatim wording from the response

“5. In addition to the above, weekly interface meetings take place which incorporate all community and inpatient services and ensure that complex cases are discussed alongside discharge meetings. If issues with attendance are identified, this is raised and actioned with clinical leads. Where regular non-attendance is identified, this is now being escalated to the Associate Director of the Clinical Business Unit.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 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

Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.

Verbatim wording from the response

“6. In order to monitor the discharge process the Trust use a safer discharge audit. This audit is used on each ward and monitors the following information:”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 2019

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.2

  1. 1

    Extend the weekend family clinic model to each inpatient ward to improve family engagement and support information gathering.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.
  2. 2

    Ensure an agreed follow-up is in place within 48 hours of discharge.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.

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

Extend the weekend family clinic model to each inpatient ward to improve family engagement and support information gathering.

Verbatim wording from the response

“3. In order to ensure family/next of kin collaboration each admission will detail family/next of kin involvement. The Trust currently holds a weekend family clinic at the Hadrian ward at the Carlton Clinic to work with families in terms of their support and collecting additional supportive information as part of each admission. This clinic is purposely held on a weekend in order to support working families. It is the Trust’s intention to extend this process to each inpatient ward as part of the long term family engagement plan. The Trust intend to extend this within a 3 month timescale. This reflects a broader plan to increase and improve family engagement in all aspects of the admission in the service.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 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

Ensure an agreed follow-up is in place within 48 hours of discharge.

Verbatim wording from the response

“4. In order to ensure that the relevant teams/services are invited to discharge meetings, this is monitored as per the Trust’s discharge flow chart. This flow chart provides prompts for teams to be invited and indicates that meeting arrangements will be agreed at least 2 days ahead unless urgent. Where attendance is not possible the flow chart states that this should be escalated to team leaders. Although this flow chart was in existence at the time of the incident, it is apparent that it was not being used consistently however, following a safer discharge project staff have been reminded to utilise this. The project includes a commitment to ensure that an agreed follow up is in place within 48 hours of discharge.”

Source location

2019-0402-Response-by-Cumbria-NHS-Trust
Page 2 · response
Published 29 December 2019

Open published response
Back to top

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