Anthony Dwyer · Prevention of Future Deaths report

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Issued 30 Jul 2015•North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

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 raised1

  1. Inadequate guidance for the general management of long-term tracheostomy patients with complex medical needs

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Department of Health and Social Care

    Responsibility for guidance on long-term tracheostomy patients with complex medical needs rests with NHS England’s patient safety team.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Department of Health and Social Care

    Existing guidance is considered adequate for staff caring for patients with a tracheostomy.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Inadequate guidance for the general management of long-term tracheostomy patients with complex medical needs

Wider context from the report

“The adequacy of guidance provided to trust in the general management long term tracheostomy patients with complex medical needs. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Responsibility for guidance on long-term tracheostomy patients with complex medical needs rests with NHS England’s patient safety team.

Verbatim wording from the response

“Guidance in this area is the responsibility of the patient safety team at NHS England. The advice I have received is that adequate guidance is already available for staff caring for patients with a tracheostomy.”

Source location

2015-0249-Response-by-Department-of-Health
Page 1 · response
Published 30 July 2015

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

Existing guidance is considered adequate for staff caring for patients with a tracheostomy.

Verbatim wording from the response

“Guidance in this area is the responsibility of the patient safety team at NHS England. The advice I have received is that adequate guidance is already available for staff caring for patients with a tracheostomy.”

Source location

2015-0249-Response-by-Department-of-Health
Page 1 · response
Published 30 July 2015

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