Recurance · prevention of future deaths reports
Pre-inquest brief
Medication monitoring and discharge risk assessment failures
The earlier warning
Susan George · 29 Feb 2016 · Lisa Hashmi, Manchester (North)
“No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November.”
judiciary.uk/prevention-of-future-death-reports/susan-george
What was promised
Stated action 1 · response to Susan George (29 Feb 2016) · stated timescale: none stated
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”
Stated action 2 · response to Sean Owen (23 Oct 2020) · stated timescale: none stated
“The Clinical Director for the Borough has established process that ensures: - All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries. - During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.”
judiciary.uk/…/2020-0215-Response-from-Pennine-Care-NHS-Foundat…
What recurred
- 26 Jul 2018 · Astonn Mitchell-Male · Lisa Hashmi
- 23 Oct 2020 · Sean Owen · Catherine McKenna · Closely related · confidence 0.80 (moderate)
- 12 Aug 2024 · David Thompson · Joanne Kearsley · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Astonn Mitchell-Male · 26 Jul 2018
“There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.”
Later · Sean Owen · 23 Oct 2020
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
What happened next
No web check of the stated actions has been published for this chain.