The Shelburne Hospital

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First report 22 Jul 2016•Latest report 22 Jul 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 The Shelburne Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Buckinghamshire

    AI-generated summary

    Stephen John Bird · 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

    Stephen John Bird underwent surgery for an Achilles tendon injury on 6 May 2016 and died at home on 11 May 2016. The recorded cause of death was pulmonary embolism due to deep vein thrombosis following recent surgery. Concerns included incomplete, inconsistent or conflicting records and an investigation report containing assumptions that conflicted with documentary records.

    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 The Shelburne Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure Significant Clinical Incident Investigation reports are based on documentary records rather than conflicting assumptions

    Wider context from the report

    “(2) Evidence given regarding the investigation by the hospital into Mr Bird’s death and the preparation of a draft Significant Clinical Incident Investigation (SCII) Report (disclosed as part of the Inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the Inquest hearing. It was indicated during the hearing that the hospital places reliance upon SCII reports as part of a learning process. ”
    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 The Shelburne Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain complete, consistent and non-conflicting patient and clinical records

    Wider context from the report

    “(1) The patient records, the documentation of consultations, clinical decisions, changes to previous assessment decisions and the discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the Inquest hearing. ”
    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