PFD report

Liam Oldsworth · Prevention of Future Deaths report

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Issued 20 Oct 2017•Lincolnshire

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

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Delays in receipt of Serious Incident Analysis reports
    Part of recurring concern: Unreliable completion and receipt of incident review reportsPart of recurring concern: Unreliable formal safety-incident management 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

Delays in receipt of Serious Incident Analysis reports

Wider context from the report

“The Serious Incident Analysis report dated 18/3/2015 has only within the last week been received by this office. Attached are recommendations and shared learning. ”

Is this part of a recurring concern?

Yes — Unreliable completion and receipt of incident review reports; Unreliable formal safety-incident management 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