Brenda Shields

1. 1. discharge without planned follow up

   “[the deceased] was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be, her GP did not receive discharge notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days after [the deceased]'s death. Referrals promised from Hadrian unit to Drug/Alcohol services and Persistent Physical Symptoms Service were not made.”

2. 2. alcohol problems not adequately addressed

   “Inadequate weight seems to have been given to [the deceased]'s alcohol problems and her assurances that all was, and would continue to be well were accepted at face value despite her recent history, her family find it hard to understand how she could be graded low risk on the day she died.”

3. 3. repeat of discharge without family involvement

   “I refer you to the PFD report I issued referring to [name redacted] on 29/10/19. Assurances were given in response to that report which again focused on discharge without family/carer involvement which is surely paramount. I note actions mentioned in the incident report in this case but am still concerned that similar events may occur in future.”

Linked reports