Skip to content
recurance

Inaccurate discharge letters to primary care

Closely relatedConfidence 0.90 · high2 reports · 2016–2019No published response to an earlier report One-page brief (print or PDF)

NHS England received 2 coroners' reports about this hazard between 24 Oct 2016 and 24 Jun 2019.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 0 specific actions.

2
reports
2
different coroners
2016–2019
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Margaret Dempsie↗

    24 Oct 2016 · Dianne Hocking · Leicester City and Leicestershire South

    “The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs [name redacted] had been suffering from aspiration pneumonia when no pneumonia had been identified”
    Original on judiciary.uk ↗
  2. 2 years 8 months later

    Raised again · 1st time

    Lewis Doyle↗

    24 Jun 2019 · Andre Rebello · Liverpool

    Closely relatedConfidence 0.90 · higha different coroner
    “When Mr [name redacted] was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr [name redacted] was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness”
    Original on judiciary.uk ↗

    Repeated from the earlier report:dischargelettercare

  3. All reports to NHS England

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error