PFD report

Tae’jelle Kaliyah Francois · Prevention of Future Deaths report

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Issued 16 Sep 2019•West Yorkshire (West)

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
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 raised1

  1. Failure to ensure timely visual assessment and escalation of seriously unwell patients at A&E admission
    Part of recurring concern: Unreliable emergency-department triage
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 ensure timely visual assessment and escalation of seriously unwell patients at A&E admission

Wider context from the report

“(1) At the point of admission into the Accident and Emergency Department, Tae’jelle was taken into the waiting area without either the Receptionist or the Triage nurse having the opportunity to visually assess her, despite Tae’jelle being in a medically critical state. Tae’jelle was taken into the waiting area of reception, where she stopped breathing. It was only as a result of the intervention of a member of the public that this condition was discovered, and as a result of that involvement Tae’jelle was taken into the Resus Department, where further treatment failed to revive her. (2) Evidence was given at the Inquest as to a Guidance recommended by The Royal College of Emergency Medicine upon dealing with the Emergency Assessment of Emergency patients. Such a Protocol provides for Reception to inform the Triage nurse of suspected seriously unwell patient, with the opportunity of then escalating the treatment of that patient. (3) Evidence was given at the Inquest that this opportunity was missed as neither the receptionist nor the Triage Nurse were provided with the opportunity to make the necessary assessment, despite the fact that the Department was not busy at the time. ”

Is this part of a recurring concern?

Yes — Unreliable emergency-department triage.

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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