Recipient

Recipient name withheld

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First report 19 Feb 2021•Latest report 19 Feb 2021

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. Brighton and Hove

    AI-generated summary

    Lisa CODLING · 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

    Lisa Codling, aged 49, took an overdose of paracetamol on 5 September 2020 after an emotionally charged encounter, and her death was confirmed by paramedics that evening. The principal concern was that the ambulance took 3 hours and 10 minutes to arrive; the inquest found that earlier arrival might have allowed ICU treatment that could have changed the outcome.

    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

    Delays in ambulance response to acute overdose emergencies

    Wider context from the report

    “(1) In her email of 12th October 2020 ████████ gave (in response to my question) her reply as to why South East Coast Ambulance Service would not be conducting a Serious Incident Report. The penultimate point stated “clinicians advise that paracetamol will not kill a patient within a 3 hour timeframe although a paracetamol overdose should still be considered in time sensitive emergency.” In this case of acute overdose the ambulance service took 3 hours and 10 minutes to arrive. Too late for Ms. Codling. ”
    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