Recipient

Recipient name withheld

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First report 27 Nov 2017•Latest report 27 Nov 2017

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. Avon

    AI-generated summary

    Shaun Mark BERRYMAN · 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

    Shaun Mark Berryman was found dead at his home address. The medical cause of death was recorded as morphine toxicity and acute bronchopneumonia, with the inquest conclusion recorded as drug-related. Concerns included a clinical assessment for a chest infection being conducted in a waiting area rather than a consultation room, no chest examination being performed, and no clinical record being made.

    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 perform chest examinations

    Wider context from the report

    “In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
    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 clinical records

    Wider context from the report

    “In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
    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 conduct clinical assessments in consultation rooms

    Wider context from the report

    “In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
    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