PFD report

Sally King · Prevention of Future Deaths report

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Issued 23 Sep 2013•Milton Keynes

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
3

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 raised3

  1. Failure to provide Pain Team assessment during hospital admission
    Part of recurring concern: Unreliable access to specialist pain care for people with chronic pain
  2. Failure to provide care and treatment on the appropriate ward or department
  3. Lack of beds delaying transfer to the Respiratory Team
    Part of recurring concern: Failure to ensure timely transfer to an appropriate hospital care environment
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 Pain Team assessment during hospital admission

Wider context from the report

“(1) Mrs. King was a patient in the hospital for over three weeks and despite numerous attempts to involve the Pain Team they proved unsuccessful and she was not seen by the team during her admission. ”

Is this part of a recurring concern?

Yes — Unreliable access to specialist pain care for people with chronic pain.

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 to provide care and treatment on the appropriate ward or department

Wider context from the report

“(2) ████████ a Consultant Orthopaedic Surgeon, in his evidence told me, “after three weeks of asking, the Respiratory Team eventually agreed to take over Mrs. King’s care. However her transfer was delayed due to lack of beds on ward 16.” Mrs. King was eventually transferred on the 6th February, the very day that she died. It would seem that she was not being cared for and treated on the appropriate ward or department. ”

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

Lack of beds delaying transfer to the Respiratory Team

Wider context from the report

“(2) ████████ a Consultant Orthopaedic Surgeon, in his evidence told me, “after three weeks of asking, the Respiratory Team eventually agreed to take over Mrs. King’s care. However her transfer was delayed due to lack of beds on ward 16.” Mrs. King was eventually transferred on the 6th February, the very day that she died. It would seem that she was not being cared for and treated on the appropriate ward or department. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely transfer to an appropriate hospital care environment.

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