PFD report

Natalie Ann Thornton · Prevention of Future Deaths report

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Issued 6 Feb 2017•Manchester North

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of a formal pump agreement
  2. Inadequate monitoring and review of blood sugar levels and pump-generated data
    Part of recurring concern: Failure to reliably measure and monitor blood glucose levels
  3. Inconsistent national support for insulin pump users
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Establishing regional centres of excellence would require major infrastructure, workforce and financial changes, and variation must first be better understood.

    Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a formal pump agreement

Wider context from the report

“1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been implemented ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate monitoring and review of blood sugar levels and pump-generated data

Wider context from the report

“1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been implemented ”

Is this part of a recurring concern?

Yes — Failure to reliably measure and monitor blood glucose levels.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inconsistent national support for insulin pump users

Wider context from the report

“2. From the evidence given by the expert Consultant ████████ it would appear that the level of support for insulin pump users nationally is variable. Whether the need for consistency and minimum standards should be addressed by Regional Centres of Excellence would be a matter for the Department to consider. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establishing regional centres of excellence would require major infrastructure, workforce and financial changes, and variation must first be better understood.

Verbatim wording from the response

“You ask the Department to consider whether the need for consistency and minimum standards for insulin pump users would be addressed by the establishment of regional centres of excellence. NHS England advises that such a move would be a significant undertaking, involving infrastructure and workforce changes and financial investment, and there is need initially to understand better the extent of variation.”

Source location

2017-0030-Response-by-Department-of-Health
Page 2 · response
Published 26 February 2017

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NICE has no plans to review the insulin pump guidance at this time.

Verbatim wording from the response

“The guidance does not make specific recommendations on support for insulin pump users. However, there are general recommendations in the guideline on early care plans, support and individualised care, as well as education and information provision for people with type 1 diabetes, which applies to pump users and non-pump users alike.”

Source location

2017-0030-Response-by-Department-of-Health
Page 2 · response
Published 26 February 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Set reducing variation in diabetes management and care as a measurable NHS mandate objective for 2020.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Set reducing variation in diabetes management and care as a measurable NHS mandate objective for 2020.

Verbatim wording from the response

“We have made achieving a measurable reduction in variation in the management and care of people with diabetes by 2020 a mandate objective for the NHS within the lifetime of this Parliament.”

Source location

2017-0030-Response-by-Department-of-Health
Page 3 · response
Published 26 February 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026