Recipient

Doctor

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First report 10 Mar 2022•Latest report 10 Mar 2022

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Suffolk

    AI-generated summary

    Colin Michael SWAIN · 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

    Colin Michael Swain was found collapsed in his front garden after drinking alcohol and was later taken to hospital following cardiac arrest and resuscitation. The inquest concluded that he died from hypoxic brain injury due to aspiration of gastric contents following alcoholic intoxication. Concerns included whether ambulance call-handling guidance adequately addressed alcohol intoxication, clearing the mouth and nose after vomiting, and turning an unconscious patient onto their back for CPR.

    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 Doctor; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of MPDS support for clearing the mouth and nose during alcohol intoxication

    Wider context from the report

    “(2) If the MPDS does provide support for alcohol intoxication, whether this includes support in how to clear the mouth and nose to good effect. If it does not, whether this something which could be included in the Tool. ”
    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 Doctor; that does not assign responsibility.

    PFD Monitor interpretation

    Potentially unsafe supine positioning of unconscious patients after vomiting

    Wider context from the report

    “(3) Whether turning an unconscious patient onto their back after vomiting is good practice, in the absence of clinician support ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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