PFD report

Jessica Florence Ashton-Pyatt · Prevention of Future Deaths report

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Issued 30 Aug 2013•South Lincolnshire

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
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 raised3

  1. Unco-ordinated staff response to immediate care
  2. Lack of consultant leadership of immediate care
    Part of recurring concern: Failure to provide effective on-duty clinical leadership
  3. Failure to maintain a ready-to-use defibrillator and defibrillation pads
    Part of recurring concern: Failure to ensure essential clinical equipment and supplies are available and serviceablePart of recurring concern: Unreliable availability and readiness of defibrillators for emergency response
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

Unco-ordinated staff response to immediate care

Wider context from the report

“The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available. ”

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 consultant leadership of immediate care

Wider context from the report

“The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available. ”

Is this part of a recurring concern?

Yes — Failure to provide effective on-duty clinical leadership.

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 a ready-to-use defibrillator and defibrillation pads

Wider context from the report

“The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available. ”

Is this part of a recurring concern?

Yes — Failure to ensure essential clinical equipment and supplies are available and serviceable; Unreliable availability and readiness of defibrillators for emergency response.

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