PFD report

Peter Embra · Prevention of Future Deaths report

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Issued 1 Mar 2016•Warwickshire

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
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

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Concerns and recipient responses

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Concerns raised1

  1. Failure to act promptly on urgent referrals for assessment
    Part of recurring concern: Unreliable social care referral pathways
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 act promptly on urgent referrals for assessment

Wider context from the report

“The local authority failed to act on an urgent referral from a GP. ████████(GP) visited Mr Embra at his home on 9 March 2015 and contacted the local authority asking for an urgent assessment. On 16 March he made a written referral to the local authority asking for an urgent assessment preferably that day. There was an approximately 7 week delay before a Social Worker visited Mr Embra. ”

Is this part of a recurring concern?

Yes — Unreliable social care referral pathways.

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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