Sister of the deceased

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First report 12 Feb 2016•Latest report 12 Feb 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

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

Concerns and recipient responses

Statements from Sister of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Ms. Marilyn Anson · 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

    Ms. Marilyn Anson had diabetes and end-stage renal failure requiring dialysis, and developed a severe left-foot pressure ulcer. An urgent referral to the ‘hot foot’ clinic was made on 26 February 2015, but the earliest appointment offered was 17 March; the ulcer deteriorated, requiring hospital admission, antibiotics and amputation surgery, and she died after further surgery on 22 March 2015. The concerns included the prioritisation and resourcing of the clinic, coordination between relevant organisations, and guidance and standardisation of referrals.

    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 Sister of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a standardised referral process for the ‘hot foot’ clinic

    Wider context from the report

    “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
    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 Sister of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic

    Wider context from the report

    “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
    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 Sister of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in prioritising urgent referrals to the ‘hot foot’ clinic

    Wider context from the report

    “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
    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 Sister of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance for referrers on clinic referral and alternative assessment and treatment options

    Wider context from the report

    “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
    Open source report
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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