Recipient

Recipient name withheld

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First report 21 Jan 2015•Latest report 21 Jan 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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire (Western)

    AI-generated summary

    Phillip Roy 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

    Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain appropriate senior medical review or support when deterioration is identified

    Wider context from the report

    “(3) Junior Doctor’s Involvement i) The senior nurse on duty was concerned of Mr. Smith’s deterioration in the early hours of the 15th March. At the time of the junior doctor’s attendance she suggested that a more senior medical review should take place, however the junior doctor indicated that he did not require any further support in the circumstances notwithstanding Mr. Smith’s presentation. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make accurate and complete doctors’ records

    Wider context from the report

    “(2) Standard of Doctors’ Records i) Junior Doctor’s involvement – neither the junior or middle grade doctors who reviewed Mr. Smith in the early hours of the 15th March 2014 made accurate records of their review and assessment of Mr. Smith. ii) Blood gasses assessment was undertaken by the junior doctor on his attendance around 1.30 a.m. but no record was made of this. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make complete and accurate nursing records

    Wider context from the report

    “(1) The Standard of Nursing Records i) On the evening of the 14th March 2014 observation were repeated 30 minutes after the standard observations were undertaken, but no record was made of these repeat observations. ii) Mr. Smith declined his evening medications, but this was not recorded. iii) Mr. Smith was given Tramadol at around 1.00 a.m. on the morning of the 15th March but this was not recorded. iv) Mr. Smith was found laid on the floor beside his bed in the early hours of the 15th March but full details of this event was not made by the nursing staff on duty. ”
    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