Next of kin

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First report 18 Oct 2016•Latest report 18 Oct 2016

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

  1. Manchester (City)

    AI-generated summary

    John Graham SMITH · 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

    Mr Smith was discharged home after admission following a fall, despite concerns about his dementia, incontinence, mobility, difficult stairs and ability to care for himself and his wife. He was readmitted after another fall at home, underwent surgery for a fractured neck of femur, developed aspiration pneumonia and died. The principal concerns were inadequate risk assessment and questioning before discharge, including insufficient consideration of his toileting needs and the difficult staircase.

    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 Next of kin; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate questioning for assessment and discharge

    Wider context from the report

    “2. Inadequate questioning for assessment and discharge purpose ████████ Consultant Orthopaedic Surgeon, agreed in court that he would not have discharged Mr Smith knowing the above. ”
    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 Next of kin; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate pre-discharge risk assessment

    Wider context from the report

    “1. Inadequate risk assessment prior to discharge – evidence heard in court confirmed that the assessment was done using 3 standard steps/stairs. There was no consideration of toilet needs requiring urgent toileting and Mr Smith having to climb a difficult staircase in a hurry. Further, there were professional and family concerns raised regarding discharge. ”
    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