Recipient

Widow of the deceased

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First report 17 Jul 2015•Latest report 17 Jul 2015

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 Widow 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

    Mr. Masoud Ghaderi · 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. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.

    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 Widow of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Ward-round planning and preparation relying solely on a brief nursing summary

    Wider context from the report

    “(3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward rounds. The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions . ”
    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 Widow of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of overarching responsibility for reviewing risk assessments

    Wider context from the report

    “(2) There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date. ”
    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 Widow of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent recording of engagement with service users

    Wider context from the report

    “(1) There was inconsistence records of engagement with service users. The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded in a consistent manner with appropriate staff training in application of the policy. ”
    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