Recipient

Son of the deceased

Pin Request correction

First report 19 Dec 2014•Latest report 19 Dec 2014

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

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Thomas Jenkins · 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

    Mr. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.

    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in Tissue Viability Nurse and wound care input

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient Tissue Viability Nurse capacity to serve the regional hospitals

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Specialist nurses not being based in the hospital for TVN and wound care input

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
    Open source report
Back to top

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