Recipient

The Shelburne Hospital

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First report 22 Jul 2016•Latest report 22 Jul 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 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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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