PFD report

Sheldon Gary Farnell · Prevention of Future Deaths report

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Issued 25 Mar 2021•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.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised5

  1. Failure to provide families’ contact details at hospital admission and discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Outdated guidance and protocols for recognition of sepsis
    Part of recurring concern: Failure to reliably recognise and respond promptly to sepsis
  3. Failure of messaging to support timely and prompt antibiotic prescribing
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

    Continue working with NHS Trusts to design policies and best practice for improving sepsis diagnosis and management.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Whether sepsis training should be mandatory is an employer decision, rather than a matter determined by the responding body.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 families’ contact details at hospital admission and discharge

Wider context from the report

“4. Contact details for families need to be positively given (not confirmed) at the time of admission and discharge within a hospital setting. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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

Outdated guidance and protocols for recognition of sepsis

Wider context from the report

“1. Guidance for the recognition of sepsis may be in need of expedited revision with protocols reflecting up to date NICE guidelines. ”

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

Failure of messaging to support timely and prompt antibiotic prescribing

Wider context from the report

“3. The messaging about the timely and prompt prescribing of antibiotic medication is in need of a review, as the Inquest highlighted issues of a possible overly cautious approach in their use, when there was no impediment to such use, and they may have saved Sheldon’s life. ”

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 deliver sepsis training through doctors with relevant current expertise

Wider context from the report

“2. Sepsis training should be mandatory and delivered by doctors with relevant experience of current research and guidance. ”

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 mandatory sepsis training

Wider context from the report

“2. Sepsis training should be mandatory and delivered by doctors with relevant experience of current research and guidance. ”

Is this part of a recurring concern?

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

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

Continue working with NHS Trusts to design policies and best practice for improving sepsis diagnosis and management.

Verbatim wording from the response

“The Government continues to work closely with NHS Trusts to design policies and best practice for improving the diagnosis and management of sepsis. Public Health England and NHSEI have recently developed a prototype for real time patient level data. We are committed to developing data linkage of infection, treatment and resistance histories to optimise life-saving treatments for serious infections, including sepsis. We understand what a fast moving and complex area of diagnosis sepsis can be. Sepsis is not a single disease but a syndrome, has no specific diagnostic test or standard case definition and presentation can vary. As a result, we recognise it can be difficult to recognise and diagnose.”

Source location

2021-0081-Response-from-Dept.-of-Health-Social-Care_Published
Page 2 · response
Published 30 March 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Whether sepsis training should be mandatory is an employer decision, rather than a matter determined by the responding body.

Verbatim wording from the response

“Regarding whether sepsis training should be mandatory, this is currently an employer decision, and I note the action taken by the South Tyneside and Sunderland NHS Foundation Trust to introduce multidisciplinary training for medical and nursing staff involved in the acute paediatric care and mandatory three-yearly sepsis training updates.”

Source location

2021-0081-Response-from-Dept.-of-Health-Social-Care_Published
Page 3 · response
Published 30 March 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Develop linked data on infection, treatment and resistance histories to optimise treatments for serious infections, including sepsis.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.

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 linked data on infection, treatment and resistance histories to optimise treatments for serious infections, including sepsis.

Verbatim wording from the response

“The Government continues to work closely with NHS Trusts to design policies and best practice for improving the diagnosis and management of sepsis. Public Health England and NHSEI have recently developed a prototype for real time patient level data. We are committed to developing data linkage of infection, treatment and resistance histories to optimise life-saving treatments for serious infections, including sepsis. We understand what a fast moving and complex area of diagnosis sepsis can be. Sepsis is not a single disease but a syndrome, has no specific diagnostic test or standard case definition and presentation can vary. As a result, we recognise it can be difficult to recognise and diagnose.”

Source location

2021-0081-Response-from-Dept.-of-Health-Social-Care_Published
Page 2 · response
Published 30 March 2021

Open published response
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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