Recipient

Husband of the deceased

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First report 9 Jun 2014•Latest report 9 Jun 2014

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 Husband 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

    Audrey Christine DAWS · 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

    Audrey Christine Daws was admitted to Derriford Hospital with chest pain and other symptoms, but her chest X-ray was delayed and its result was not identified promptly. The X-ray eventually showed air under the diaphragm indicating a perforation; she underwent surgery, deteriorated and died. The principal concerns were inadequate handover of outstanding investigations and delays in ordering, performing and reviewing the X-ray.

    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 Husband of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hand over outstanding investigations and required result checks during staff shift changes

    Wider context from the report

    “1. Handover of Information. The need for Mrs Daws to undergo a chest X-ray and for the result to be checked appears to have been lost as medical staff have changed at the end/start of consecutive shifts. You may wish to consider whether there needs to be a formal handover in respect of every patient where outstanding investigations are highlighted. ”
    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 Husband of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and address prolonged delays in urgent investigations

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”
    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 Husband of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to order an indicated chest X-ray promptly on emergency department admission

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”
    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 Husband of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in performing urgent investigations

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”
    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 Husband of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in medical review of investigation results

    Wider context from the report

    “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”
    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