PFD report

Vilmantas Venskutonis · Prevention of Future Deaths report

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Issued 21 Apr 2021•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. Failure to implement the action plan in full
    Part of recurring concern: Failure to implement identified safety actions
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 implement the action plan in full

Wider context from the report

“I refer to the action plan dated December 2019 that was attached to the SI report, Lead Investigator, Dr ████████ (Cardiology). The commencement of the plan is January 2020. There are nine points to this plan, I need to know if the plan has been implemented in full to prevent further deaths with implementation dates for all 9 points. If not implemented in full or in part please state reason why identifying each point. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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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