Recipient name withheld

First report 2 Jul 2015•Latest report 2 Jul 2015

Reports, concerns and published responses

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

2 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to ensure surgeons acknowledge having read applicable clinical guidelines
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs. Gail Prentice · 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

Mrs. Gail Prentice, aged 46, died after severe bleeding during an attempted percutaneous tracheostomy, caused by transection of the brachiocephalic artery. The report describes concerns about tracheostomy in altered neck anatomy following previous surgery, including the need for appropriate imaging and site selection, and about surgeons acknowledging relevant hospital and other guidelines.

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 ensure surgeons acknowledge having read applicable clinical guidelines
Wider context from the report
“(1) The requirement for surgeons to acknowledge having read the Health Board’s Hospital Guidelines and those of other bodies e.g. NICE Guidelines ”
Open source report

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