Recipient

Next of kin

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First report 18 Oct 2016•Latest report 18 Oct 2016

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 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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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