Recipient

Recipient name withheld

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First report 20 Apr 2017•Latest report 20 Apr 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. Birmingham and Solihull

    AI-generated summary

    Johan Stone Pambou · 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

    Johan Stone Pambou, who had sickle cell disease, was admitted with severe abdominal and joint pain and later deteriorated, was diagnosed with pneumococcal septicaemia, and died on 11 December 2016. Concerns included failures by the GP practice to act on four hospital letters requesting pneumovax 23 vaccination, and concerns about the vaccine’s availability and whether GPs understood how to access it.

    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

    Lack of an adequate system to monitor and act on hospital letters

    Wider context from the report

    “1. System and record keeping in the GP practice. Four letters were received asking for this child to receive pneumovax 23 vaccination from February 2016 to November 2016. None of the letters were actioned by the GP. They were simply filed away. I am concerned that there was no adequate system in place to monitor and act on letters received from hospitals which means other essential treatment may be missed for other patients. ”
    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 of GPs to understand where to access Pneumovax 23 vaccine

    Wider context from the report

    “2. Availability of pneumovax vaccine 23. I heard evidence from the GP in this case that attempts were made to obtain the vaccine in June 2016 but it was unavailable. I was also told the vaccine continued to be unavailable now. I am concerned about the availability of the vaccine and whether GPs fully understand where to access the vaccine. ”
    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 Pneumovax 23 vaccine

    Wider context from the report

    “2. Availability of pneumovax vaccine 23. I heard evidence from the GP in this case that attempts were made to obtain the vaccine in June 2016 but it was unavailable. I was also told the vaccine continued to be unavailable now. I am concerned about the availability of the vaccine and whether GPs fully understand where to access the vaccine. ”
    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