Recipient

Family of the deceased

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First report 10 Jul 2015•Latest report 10 Jul 2015

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

  1. Manchester North

    AI-generated summary

    Colin Moulton · 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 Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.

    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 of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma

    Wider context from the report

    “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse. ”
    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 of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to notify the hospital trust of ambulance presence within hospital grounds

    Wider context from the report

    “2. At approximately 5pm on the 13th February 2013, a number of administrative staff, whilst en-route home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to be ‘ in difficulty’. One of the staff members called for the assistance of an ambulance which duly attended and a paramedics on board apparently were unable to locate Mr Moulton. Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware. The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital Trusts might be notified in such circumstances. ”
    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 of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma

    Wider context from the report

    “1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse. ”
    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