PFD report

Michelle Roach · Prevention of Future Deaths report

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Issued 28 Nov 2018•Berkshire

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
6

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

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 raised6

  1. Lack of knowledge of the signs and symptoms of venous thromboembolism
  2. Insufficient medical registrar cover at night
    Part of recurring concern: Insufficient qualified healthcare staffing capacityPart of recurring concern: Insufficient safe staffing and senior cover out of hours
  3. Deficient GP record-keeping practices
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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

Lack of knowledge of the signs and symptoms of venous thromboembolism

Wider context from the report

“(1) I believe ████████ should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism. ”

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

Insufficient medical registrar cover at night

Wider context from the report

“(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity; Insufficient safe staffing and senior cover out of hours.

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

Deficient GP record-keeping practices

Wider context from the report

“(2) I believe ████████ should review her record-keeping practices. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Insufficient clinical knowledge of unexpected deaths and related clinical management

Wider context from the report

“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”

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

Failure of the GP practice system to investigate unexpected deaths

Wider context from the report

“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review; Inadequate safety incident investigations.

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

Deficient GP record keeping

Wider context from the report

“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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