PFD report

Christina Bernadette Withey · Prevention of Future Deaths report

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Issued 7 Apr 2017•Wiltshire and Swindon

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.

View original report
Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

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

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

Concerns raised5

  1. Failure to keep patient records relating to urine charts
    Part of recurring concern: Unreliable recording of fluid balance information
  2. Failure to accurately measure urine output
    Part of recurring concern: Failure to reliably monitor patient fluid balance
  3. Lack of review of sepsis guidelines against the Acute care toolkit 9: sepsis
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 patient records relating to urine charts

Wider context from the report

“(1) The keeping of patient records in relation to a urine chart and the accurate measuring of output. ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

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

Failure to accurately measure urine output

Wider context from the report

“(1) The keeping of patient records in relation to a urine chart and the accurate measuring of output. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor patient fluid balance.

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

Lack of review of sepsis guidelines against the Acute care toolkit 9: sepsis

Wider context from the report

“(3) Review of the sepsis guidelines in the light of the “Acute care toolkit 9: sepsis” produced by The Royal College of Physicians ”

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

Delays in reviewing patients whose condition has not improved

Wider context from the report

“(2) The period before a review of a patient is carried out where there has been no improvement in condition. ”

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

Lack of training for locums and other temporary staff

Wider context from the report

“(4) The training of locums and other temporary staff ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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