Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Graham Watts · 3 Apr 2014 · Veronica Hamilton-Deeley, Brighton & Hove
“(1) That the Discharge procedure followed in respect of Mr. [name redacted]' discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4”
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…
Stated action 2 · response to Evelyn Kennedy (7 May 2015) · stated timescale: last autumn
“The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”
judiciary.uk/…/2015-0178-Response-by-Brighton-and-Sussex-Univer…
What recurred
- 7 May 2015 · Evelyn Kennedy · Veronica Hamilton-Deeley
- 20 Apr 2017 · Patricia Webb · Veronica Hamilton-Deeley · Closely related · confidence 0.90 (high)
- 1 Oct 2018 · Joan Blaber · Veronica Hamilton-Deeley · Closely related · confidence 0.80 (moderate)
- 14 Feb 2019 · Kenneth Whittington · Veronica Hamilton-Deeley · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Evelyn Kennedy · 7 May 2015
“Handover was incomplete and unhelpful.”
Later · Kenneth Whittington · 14 Feb 2019
“His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.”
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.
No evidence found either way · stated action 2
“The new Acute Medical Unit (AMU) at the Royal Sussex County Hospital also includes a same day care unit, which offers patients who do not need an overnight stay access to 24-hour specialist care.”
New units officially open at the Royal Sussex County Hospital · bbc.com/news/articles/c043edwyg9ro
“University Hospitals Sussex NHS Foundation Trust.”
Brighton & Sussex University Hospitals NHS Trust - We are now UHSussex. Please follow our new LinkedIn page. · linkedin.com/…/brighton-%26-sussex-university-hospitals-nhs-tru…
No evidence found does not mean the action did not happen.