Daughter of the deceased

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First report 8 Apr 2014•Latest report 8 Apr 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Daughter of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Plymouth, Torbay and South Devon

    AI-generated summary

    Leslie Edmund Harding (Lez) · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure prompt treatment of suspected life-threatening conditions

    Wider context from the report

    “1. ████████ took no action during the period from 18 – 28 September 2013. Patients with a suspected life-threatening condition (Pulmonary Embolus) must be promptly treated. The system for ensuring that the treatment is provided must be robust. That is particularly the case where it is already known that the patient suffers from an underlying condition that makes him prone to the particular life-threatening event. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct timely significant-events review of a death

    Wider context from the report

    “4. I was advised that this death had not yet been reviewed in a significant events meeting. In my view, that should have taken place forthwith after Lez’s death. You may wish to convene a significant events ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure continuity of required anticoagulation medication

    Wider context from the report

    “3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to address suspected non-compliance with lifelong anticoagulation

    Wider context from the report

    “3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check for omissions in anticoagulation treatment for other patients

    Wider context from the report

    “2. Your practice will have a number of other patients in receipt of anti-coagulation treatment following recurrent Pulmonary Embolii. Given the omission that appears to have occurred here, you need to ensure that no other omissions have happened with any of the other patients ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026