PFD report

Jude Daniel Kliem · Prevention of Future Deaths report

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Issued 29 Aug 2014•Plymouth, Torbay and South Devon

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Lack of standardised documentation
  2. Failure to maintain effective communication
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Develop a national referral and retrieval format as part of a process supporting senior clinical discussion and agreement on appropriate action.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 August 2014.

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 standardised documentation

Wider context from the report

“There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation ”

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

Failure to maintain effective communication

Wider context from the report

“There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Develop a national referral and retrieval format as part of a process supporting senior clinical discussion and agreement on appropriate action.

Verbatim wording from the response

“There is clearly an opportunity to further improve safety by bringing together the best aspects of the existing formats into a single document. Such a document would contain the key content needed for safe and effective referral and retrieval, to which suitable local or specialist requirements might be added.”

Source location

2014-0464-Response-by-Department-of-Health
Page 2 · response
Published 29 August 2014

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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