PFD report

Yvonne Sydney Annie Perry · Prevention of Future Deaths report

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Issued 23 Sep 2013•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
2

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

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Concerns raised2

  1. Lack of a robust process for tracking review of radiology reports by emergency department consultants
    Part of recurring concern: Unreliable review of diagnostic imaging before consequential care decisions
  2. Lack of access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable access to relevant clinical records for safe care
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

Lack of a robust process for tracking review of radiology reports by emergency department consultants

Wider context from the report

“(1) That the x-ray taken of Mrs. Perry’s hip, reported on by the consultant radiologist on the 19th December 2012, was not acted upon until the 3rd January 2013. It was recognised that the Hospital “do not have a robust process for tracking that the emergency department consultants have looked at the radiology reports.” Without such a system I believe further deaths may occur in the future. ”

Is this part of a recurring concern?

Yes — Unreliable review of diagnostic imaging before consequential care decisions.

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 access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit

Wider context from the report

“(2) The GPs who attend the Windsor Intermediate Care Unit do not have access to the electronic hospital notes and records and those witnesses from WICU who attended the inquest considered that such access would improve the care afforded to patients. Similarly without access to the patients notes further deaths may occur in the future. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable access to relevant clinical records for safe care.

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