“The social workers left work on Friday 8th March, 2013 believing that, following their…”

The coroner’s concerns

– (1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural Causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to them. (2) The clinician discharged Ms Ferguson based on clinical issues and NICE guidelines. She was discharged to the care of her friend The only conversation between the clinicians and was a telephone call in which it was arranged for Ms Ferguson to be driven straight to his home on leaving hospital. This duly took place, but did not understand that the clinician expected him to remain in her company for at least the next 24 hours in order to watch for any significant changes in her condition and accordingly, he did not remain with her constantly. There was clearly a difference of perception about his role, possibly as a result of a lack of clarity in the conversation between himself and the clinician. I am concerned that a repetition of this in other cases may lead to danger. (3) The Hospital Notes were scanty and there appear to be material omissions to record important decisions such as a detailed note of the telephone call between and the clinician, properly timed and recording clearly what was intended. Further, it was difficult to trace from the Notes, the actual day of th discharge, the clinician believing it to be the 8 March and th believing it was the 9 March. Some computer records were presented to the Court suggestive of a discharge on the 8th March, but this information appears to be missing from the actual hand-written Notes. I am concerned that such problems with communication can lead to misunderstandings to the detriment of all concerns.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2013-0365

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0