PFD report

Esther Jane Jones · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 2 Jul 2014•North Wales (East and Central)

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
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

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure of the process for conducting and completing SIRs
    Part of recurring concern: Unreliable completion and receipt of incident review reports
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 of the process for conducting and completing SIRs

Wider context from the report

“That unless steps are taken to improve the process by which SIRs are conducted and completed, then this could pose continuing risks to others and may lead to future deaths. ”

Is this part of a recurring concern?

Yes — Unreliable completion and receipt of incident review reports.

Open source report
Back to top

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