PFD report

Thomas David Dixon · Prevention of Future Deaths report

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Issued 8 Jul 2014•Sunderland

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
4

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

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

Concerns raised4

  1. Failure to provide follow-up appointments within the required timeframe
    Part of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
  2. Missing referral documentation for procedures
  3. Lack of systems to identify and rectify problems
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 provide follow-up appointments within the required timeframe

Wider context from the report

“(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014 (4) There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up. I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements. However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths ”

Is this part of a recurring concern?

Yes — Unreliable arrangement and communication of patient appointments and follow-up.

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

Missing referral documentation for procedures

Wider context from the report

“(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014 (4) There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up. I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements. However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths ”

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 systems to identify and rectify problems

Wider context from the report

“(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014 (4) There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up. I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements. However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths ”

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 provide urgent procedure appointments within the required timeframe

Wider context from the report

“(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012 (2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013 (3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014 (4) There appeared to be no systems in place to identify and take action to rectify these problems. Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up. I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements. However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths ”

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