Recipient

Recipient name withheld

First report 19 Jun 2018•Latest report 19 Jun 2018

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

19 Jun2018
Shropshire, Telford and Wrekin
Concerns raised8
1. Failure to provide Shropdoc personnel with access to referring patients’ GP records
2. Failure to remove leg bandages for full top-to-toe examination
3. Lack of a programme to replace unavailable A&E Doctors
1. Failure to follow Sepsis Six care bundles in accordance with guidelines
2. Unavailability of prescribed drugs in the A&E department
3. Failure to identify red flag signs of sepsis
4. Insufficient A&E Doctor staffing to cover patient needs
5. Failure to consider suitable alternative drugs when the prescribed drug is unavailable
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Patricia Violet PALIN · 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

Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.

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 provide Shropdoc personnel with access to referring patients’ GP records
Wider context from the report
“1. Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records. This meant that they did not have the full picture of Patricia’s past medical history before administering any advice or treatment. This is not a one off isolated incident and applies to every case that is referred to Shropdoc. Evidence was given at the inquest from the Shropdoc Urgent Care Practitioners that it would have assisted them. ”
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 remove leg bandages for full top-to-toe examination
Wider context from the report
“4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence; a. Red flag signs of sepsis were missed. b. Leg bandages were not removed to allow full top to toe examination. c. Sepsis six care bundles were not followed in accordance with guidelines. ”
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
Lack of a programme to replace unavailable A&E Doctors
Wider context from the report
“2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick. ”
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 follow Sepsis Six care bundles in accordance with guidelines
Wider context from the report
“4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence; a. Red flag signs of sepsis were missed. b. Leg bandages were not removed to allow full top to toe examination. c. Sepsis six care bundles were not followed in accordance with guidelines. ”
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
Unavailability of prescribed drugs in the A&E department
Wider context from the report
“3. I heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered. ”
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 identify red flag signs of sepsis
Wider context from the report
“4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence; a. Red flag signs of sepsis were missed. b. Leg bandages were not removed to allow full top to toe examination. c. Sepsis six care bundles were not followed in accordance with guidelines. ”
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
Insufficient A&E Doctor staffing to cover patient needs
Wider context from the report
“2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick. ”
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 consider suitable alternative drugs when the prescribed drug is unavailable
Wider context from the report
“3. I heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered. ”
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

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure to provide Shropdoc personnel with access to referring patients’ GP records

Failure to remove leg bandages for full top-to-toe examination

Lack of a programme to replace unavailable A&E Doctors

Failure to follow Sepsis Six care bundles in accordance with guidelines

Unavailability of prescribed drugs in the A&E department

Failure to identify red flag signs of sepsis

Insufficient A&E Doctor staffing to cover patient needs

Failure to consider suitable alternative drugs when the prescribed drug is unavailable