Recipient

Parents of the deceased

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First report 6 Nov 2023•Latest report 6 Nov 2023

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

  1. Avon

    AI-generated summary

    Ms. Madeleine Lawrence · 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

    Ms. Madeleine Lawrence suffered a traumatic hip dislocation while playing rugby and later developed sepsis and necrotising myositis after her hospital admission. Her condition deteriorated, but observations were not performed or escalated in a timely manner, and prompt treatment for presumed sepsis was not initiated; she died in hospital on 25 March 2022. The concerns identified included serious deficiencies affecting patient safety and the adequacy of staff training on recognising and treating deteriorating patients and sepsis.

    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 Parents of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Serious deficiencies affecting patient safety at Southmead Hospital, Bristol

    Wider context from the report

    “(1) That serious deficiencies affecting the safety of patients at Southmead Hospital, Bristol which had been identified following the death of Ms. Lawrence ”
    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 Parents of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure training of current staff and ongoing training for new staff

    Wider context from the report

    “(2) The CQC should confirm that it is now satisfied that the Trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff. ”
    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