Recipient

Family

Pin Request correction

First report 23 Oct 2025•Latest report 23 Oct 2025

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

  1. Black Country

    AI-generated summary

    Mrs Rashida Sultana · 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

    Mrs Rashida Sultana died on 20 November 2024 after choking on chips and water while admitted to hospital. Concerns included confusion among nursing staff about when to call the Emergency Medical Response Team when a DNAR was in place, and insufficient risk assessment regarding Speech and Language Therapy assessments for patients at risk of dysphagia.

    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 Family; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of nursing staff understanding of when to call the EMRT during emergencies involving a DNAR

    Wider context from the report

    “2. My concern is that there was confusion and lack of understanding by nursing staff in relation to when the EMRT should be called in an emergency particularly when a DNAR was place. ”
    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 Family; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia

    Wider context from the report

    “3. In addition, there was a lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place. ”
    Open source report
Back to top

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