Care and discharge planning
520 items
2 sources
Failure to develop detailed and comprehensive client assessments, recovery plans, and discharge plans.
Cross-Source Insight
Care and discharge planning has been flagged across 2 independent accountability sources:
9 inquiry recs
511 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (9)
BRIS-20 — Establish comprehensive counselling and support services as integral to patient care
Recommendation: The provision of counselling and support should be regarded as an integral part of a patient’s care. All hospital trusts should have a well-developed system and a well-trained group of professionals whose task it is to provide this type of …
Unknown
BRIS-21 — Require every trust to provide a professional bereavement service and online information
Recommendation: Every trust should have a professional bereavement service. (We also reiterate what was recommended in the Inquiry’s Interim Report: ‘Recommendation 13: As hospitals develop websites, a domain should be created concerned with bereavement in which all the relevant information concerning …
Unknown
F239 — Continuing responsibility for care
Recommendation: The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F256 — Follow up of patients
Recommendation: A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
R6 — Service change continuity plans
Recommendation: Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care.
Gov response: Section 2.1 of the Scottish Government's response details the intention to develop a longer-term plan for health and social care, and the integration of health and social care services. This integration aims to improve care, …
Accepted
LAMI-56 — Prevent discharge of hospitalised children with concerns until home is safe
Recommendation: Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
PFD Reports (511) — showing 100 most recent
Liam Sutton
Concerns: Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.
Pending
Barbara Wingate
Concerns: Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Pending
Pamela George
Concerns: The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.
Pending
Linda Fury
Concerns: The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.
Overdue
Stephen Taylor
Concerns: Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.
Response: Vita Health Group reviewed and updated its Duty Standard Operating Procedure in November 2025 to mandate same-day actioning of routine referrals and emphasize careful consideration of family information in clinical …
Response: Kent and Medway Mental Health NHS Trust has updated its Urgent Mental Health Helpline Standard Operating Procedure, including clearer high-risk categories, faster triage (from 72 to 24 hours), and new …
Responded
Peter Thompson
Concerns: Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Response: Bank Close House has strengthened documentation expectations for handovers and instructed staff to immediately request blood glucose tests from external professionals for ill diabetic residents. Blood glucose monitoring equipment is …
Responded
David Dugdale
Concerns: Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
Overdue
Mohammed Choudhury
Concerns: Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
Response: The Trust has reinforced operational policies for medication non-concordance, requiring formal MDT discussion and documentation of missed depot injections, and embedded an audit cycle for compliance. All relevant staff have …
Responded
Timothy Reading
Concerns: The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components for S.117 plans.
Pending
Tracey Oldfield
Concerns: Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
Response: Royal Cornwall Hospital has established a multidisciplinary group to strengthen governance for timely prescribing of medications for unexpectedly admitted day-case patients. They have identified four workstreams, including ensuring systems alert …
Responded
Jacqueline Aarons
Concerns: A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Response: The Department for Health and Social Care acknowledges the concerns but states that these matters are more appropriately addressed by NHS England directly, who will provide a full and comprehensive …
Responded
Ernest Gray
Concerns: The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.
Response: East Kent Hospitals has updated their discharge checklist to ensure identification of main carers, developed a care advice leaflet for patients with carers, and implemented a 'carer's passport' and a …
Responded
Richard Worswick
Concerns: Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Response: Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones with mitigation …
Response: Stockport NHS Foundation Trust has issued a Trust-wide alert (20 November 2025) requiring two copies of Transfer of Care documentation to be printed: one for the patient and one for …
Responded
Lynn Silcock
Concerns: A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Response: NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline …
Response: The Trust has initiated a Patient Safety Investigation (PSII), completed a review of discharge processes in Gastroenterology with Cardiology input, and created a new policy for referrals. A single referral …
Responded
Thompson Elliott
Concerns: Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Response: Care UK has conducted extensive staff discussions and reminded all care homes of internal policies on discharge information and handover procedures. The Grangewood care home has updated its contact document …
Responded
William Roath
Concerns: A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors to prevent recurrence are still outstanding.
Response: University Hospitals Birmingham NHS Foundation Trust has delivered comprehensive training to doctors on recognizing and acting upon swallowing difficulties, emphasizing clear documentation and communication. A new bespoke module on 'the …
Responded
Jillian Steedman
Concerns: Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated crises and professional warnings.
Response: Essex County Council has undertaken joint work with EPUT resulting in an updated PSIRF Policy. They are reviewing Mental Health Act obligations and their Approved Mental Health Professional service, and …
Response: The Trust held post-inquest debriefs, implemented a new Communication and Handover Procedure Policy (16 Oct 2025), and established daily virtual Bed Management and Flow meetings to improve information sharing. They …
Responded
Brian Ingram
Concerns: Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
Overdue
Angela Thompson
Concerns: A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Response: HM Prison and Probation Service highlights the establishment of Regional Health & Justice Teams and regular multidisciplinary meetings to improve integrated health services and support transitions. It also notes the …
Response: HMPPS has established Regional Health & Justice Teams and a central Deaths Under Supervision Team to improve integrated health services and liaison for prison leavers. Learning from this case will …
Responded
Christian Marsh Prevention of future deaths report
Concerns: There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant risk.
Responded
John Franklin
Concerns: A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety post-discharge.
Overdue
James Cochrane
Concerns: There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.
Responded
Edwin Price
Concerns: A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.
Responded
Masood Hamid
Concerns: There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.
Responded
REDACTED
Concerns: Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.
Responded
Valerie Hampson
Concerns: The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.
Responded
David Bendell
Concerns: A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
Responded
Cain Donald
Concerns: Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to mental health deterioration.
Responded
Esther Byrne
Concerns: Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.
Responded
Callum Hargreaves
Concerns: The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.
Responded
Callum Hargreaves
Concerns: The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.
Responded
Sarah Hill
Concerns: Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.
Responded
Janet Anderson
Concerns: A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Responded
Samuel Brookes
Concerns: A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.
Overdue
Jonathan Hamer
Concerns: Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Responded
Mr YZ
Concerns: Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the user's distress.
Responded
Andrew Tizard-Varcoe
Concerns: Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and inappropriate discharge decisions for a progressing infection.
Responded
Derrick Tully
Concerns: Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient deterioration, leading to missed care needs.
Responded
Winnie Harrop
Concerns: Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in discharge letters.
Responded
Billie Wicks
Concerns: The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and ineffective safety netting advice contributed to the death.
Responded
Jean Pike
Concerns: Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Responded
Annette Lewis
Concerns: Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency departments.
Responded
Mark Fernandez
Concerns: Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term carers and social services.
Responded
Ann Cotgrove
Concerns: There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Responded
Duncan Holloway
Concerns: Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
Responded
Brigitte Favre
Concerns: A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking adverse outcomes.
Response: West Suffolk NHS Foundation Trust has implemented a new Oncology discharge planning tool, launched in February 2026, to standardise communication and inform discharge decision-making. They are also exploring a 7-day …
Responded
Katrina Insleay
Concerns: The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed follow-up and increased wound infection.
Responded
Nicola Owens
Concerns: Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response capacity.
Responded
Naomi Suleyman
Concerns: Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
Overdue
William Bissett
Concerns: Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
Responded
Charlie Marriage
Concerns: Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency medication access.
Responded
Sheila Wexler
Concerns: A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care and prolonged immobility.
Responded
Eden Street
Concerns: Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Responded
Mark-Anthony Summersett
Concerns: A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a vulnerable patient.
Responded
David Tighe
Concerns: The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
Responded
Mary Whitlock
Concerns: A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary or safety netting advice for a vulnerable patient.
Responded
Craig Spiby
Concerns: Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Responded
Raymond Reid
Concerns: Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.
Responded
Kenneth King
Concerns: Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training program and policy for preventing untrained bank staff from working are significantly delayed.
Responded
Jaipreet Panesar
Concerns: A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.
Responded
Alison Binyon
Concerns: Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.
Responded
Janet Brown Townend
Concerns: Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.
Overdue
Phyllis Tromans
Concerns: A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.
Responded
Kingsley Imafidon
Concerns: Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.
Responded
Bryan and Mary Andrews
Concerns: A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.
Responded
Kevin Woods
Concerns: Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.
Responded
Megan Williams
Concerns: Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Responded
Kelly Stevens
Concerns: A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.
Responded
George Coulthard
Concerns: Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community wound care access further exacerbated health risks.
Responded
Dennis Harry
Concerns: Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.
Responded
Margaret Maycroft
Concerns: The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that steps have been taken to ensure proper documentation and consideration of these measures.
Responded
Evelyn March
Concerns: An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the baby's death when she fell asleep during breastfeeding. This raises concerns about the timing of postpartum discharges.
Responded
Emilia Allsopp
Concerns: A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.
Responded
Matthew Gale
Concerns: Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in a new policy increases future risks.
Responded
David Thompson
Concerns: Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior admissions or community support.
Responded
Gillian Stokes
Concerns: Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Responded
Kieran Lavin
Concerns: Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking specific questions for comprehensive evaluation.
Responded
Maria de Ceita
Concerns: A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a fatal fall. This highlights a systemic failure in managing elderly patient fall risks.
Responded
Danny Anderson
Concerns: There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked understanding of robust risk assessment and safety planning.
Responded
Omar Ahmed
Concerns: Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health deterioration and inadequate living conditions.
Responded
Paul Holmes
Concerns: Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
Overdue
Thomas Geraghty
Concerns: A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when patients are removed, risking their health.
Responded
Andrew Naylor
Concerns: There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug treatment teams hindered safe discharge planning.
Responded
Nigel Dixon
Concerns: Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a significant overdose risk.
Overdue
Frazer Williams
Concerns: A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.
Overdue
Christopher MacGillivray
Concerns: Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals released at short notice.
Overdue
Jonathan Szczepanski
Concerns: Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.
Responded
Carol Divall
Concerns: Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis further compounded the issues.
Responded
Sally Poynton
Concerns: An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness who declined treatment, created significant care gaps.
Overdue
Linda Heath
Concerns: Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also an over-reliance on private care with insufficient oversight.
Responded
Karen Thomason
Concerns: Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.
Responded
Mohamed Ellaboudy
Concerns: Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking patient safety.
Responded
Richard Carpenter
Concerns: Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of preventable deaths for patients requiring timely hospital transfer.
Responded
Timothy Clayton
Concerns: Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.
Responded
Margaret Burman
Concerns: Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.
Responded
Darren Docherty
Concerns: Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Overdue
Michael Burke
Concerns: Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.
Responded
Ellen Woolnough
Concerns: Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.
Responded
Sarah Adams
Concerns: Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.
Responded
Robert Prowse
Concerns: Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and exacerbating emergency department overcrowding.
Responded