PFD report

Roger Albert NEAVES · Prevention of Future Deaths report

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Issued 18 Apr 2019•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
1

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

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Concerns and recipient responses

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Concerns raised1

  1. Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations
    Part of recurring concern: Unreliable root cause analysis processes
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 confirmation of fulfilment of Root Cause Analysis recommendations

Wider context from the report

“The Coroner received evidence from ████████ the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves’s death. That Root Cause Analysis made various recommendations which required action by the Hospital Trust. The Coroner is concerned to receive confirmation that the recommendations have been fulfilled. ”

Is this part of a recurring concern?

Yes — Unreliable root cause analysis processes.

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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