PFD report

Iain Neil MACINNES · Prevention of Future Deaths report

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Issued 24 Sep 2019•Milton Keynes

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised1

  1. Failure to keep patients’ families informed of significant changes in care
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Failure to keep patients’ families informed of significant changes in care

Wider context from the report

“During the course of the evidence it became apparent that, despite the fact that the deceased had indicated that he wanted information to be shared with his family and for them to be involved in his care, they were not informed that his condition had deteriorated and that he had been transferred to the Home Treatment Team although it was widely accepted that it is important that the family are involved in a patients treatment and care. The process for recording details of the family and for keeping them informed needs to be reviewed by the trust and proposals for reform considered. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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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