Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Graham Watts · 3 Apr 2014 · Veronica Hamilton-Deeley, Brighton & Hove
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
judiciary.uk/prevention-of-future-death-reports/graham-watts
What was promised
Stated action 1 · response to Graham Watts (3 Apr 2014) · stated timescale: 27 May 2014
“the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily”
judiciary.uk/…/2014-0149-Response-by-Brighton-Sussex-University…
What recurred
- 12 Aug 2015 · Thelma Jones · Veronica Hamilton-Deeley · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Graham Watts · 3 Apr 2014
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
Later · Thelma Jones · 12 Aug 2015
“* firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
What happened next
No evidence found either way · stated action 1
“The development of plan has been clinically led and will have strong clinical oversight of its implementation.”
2025/26 Winter Planning Priorities - NHS Sussex · sussex.ics.nhs.uk/…/2.6-202526-Winter-Planning-Priorities.pdf
“Read article](/resources/understanding-medically-fit-for-discharge-mffd-status-in-the-nhs)”
Patient Flow | Lazomis QI Resource Library · lazomis-qi.co.uk/resources/category/patient-flow
“A recent report by the [Health Service Journal](https://www.hsj.co.uk/quality-and-performance/2bn-cost-of-delayed-discharges-revealed-for-first-time/7040178.article) has revealed the £2bn cost of delayed discharges.”
Discharge Delays are costing the NHS £2bn - Develop Consulting · develop-consulting.co.uk/news/discharge-delays-costing-nhs-2bn
No evidence found does not mean the action did not happen.