PFD report

Stephen Anthony Allardice Widman · Prevention of Future Deaths report

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Issued 29 Apr 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.

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Concerns
3

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 raised3

  1. Lack of an accelerated Accident and Emergency pathway for individuals suffering neutropenic sepsis
    Part of recurring concern: Failure to reliably recognise and respond promptly to sepsis
  2. Lack of urologist management of catheterised patients
  3. Failure to limit catheterisation frequency
    Part of recurring concern: Unsafe catheterisation practice
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 an accelerated Accident and Emergency pathway for individuals suffering neutropenic sepsis

Wider context from the report

“1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond promptly to sepsis.

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 urologist management of catheterised patients

Wider context from the report

“1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. ”

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 limit catheterisation frequency

Wider context from the report

“1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. ”

Is this part of a recurring concern?

Yes — Unsafe catheterisation practice.

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