Solicitors for family

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First report 19 Jun 2018•Latest report 19 Jun 2018

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 Solicitors for family linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Shropshire, Telford and Wrekin

    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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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 Solicitors for family; 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
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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