84-year-old male initially admitted with acute kidney injury The discharge summary requested the GP to monitor urea and electrolytes (U+E) after discharge, and continue with a reduced dose of furosemide only if the U+E was ‘OK’. Although the initial dose reduction was made, the patient’s furosemide was continued for 5 months, despite worsening chronic kidney disease (CKD). Despite a doubling of the creatinine level to >900 µmol/L, the advice regarding furosemide was not heeded. This worsening of CKD5 (glomerular filtration rate <15ml/min) led to the patient needing dialysis.

94-year-old female initially admitted with fast atrial fibrillation due to sepsis There were eight medications changes requested on the discharge summary (including three new cardiac drugs — digoxin, rivaroxaban, and bisoprolol — and two dose changes, furosemide and gliclazide. This patient was medically very complex, with multiple morbidities, including heart failure. The discharge summary requested the GP to increase furosemide from 20 mg to 40 mg twice daily, but this change was not made. The patient had a subsequent hospital admission with cardiac failure within a few months of the initial discharge.

86-year-old male initially admitted with aspiration pneumonia This immobile patient had multiple morbidities and recurrent episodes of aspiration pneumonia following a stroke. The GP did not order the follow-up chest X-ray requested by the hospital for 6 weeks following discharge. The patient subsequently died from aspiration pneumonia 4 months later. The death could have been connected to a missed opportunity to diagnose aspiration pneumonia on an earlier chest X-ray.

76-year-old female initially admitted with exacerbation of chronic obstructive pulmonary disease During the admission, Seretide was replaced with Fostair as the patient was ‘unable to use (Seretide) effectively’. The discharge summary also requested the GP to prescribe carbocisteine to ‘bring up phlegm’(these were the only requests made on the discharge summary). No change was made to the inhaled therapy following discharge, and carbocisteine was not initiated. The patient was admitted with a further exacerbation of COPD subsequently in the 9 months between discharge and the date of data collection.