Inadequate discharge decision analysis

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2020 → 2026Linda Fury5 years 9 months after Gordon Fenton · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight deficiencies in decision‑making processes concerning patient care and discharge planning. The earlier report cites missing formal cross‑trust review, while the later report notes inadequate analysis of internal discharge decisions.

  Gordon Fenton · 23 Apr 2020

  “There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs.”

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  Linda Fury · 20 Jan 2026

  “The investigation does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”

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  Stated action in the response to the earlier report

  “The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr [name redacted] was a patient. The offering of Digital Health services will be conducted”

  Earlier report in the app · Later report in the app