PFD report

Alan Stanfield · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 26 Nov 2013•Avon

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
2

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 raised2

  1. Failure to ensure family involvement in accommodation arrangements before discharge
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisions
  2. Failure to ensure proper accommodation is provided before discharge
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residents
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 ensure family involvement in accommodation arrangements before discharge

Wider context from the report

“1. Mr. Browning was discharged from Somewhere House without his family being informed of arrangements for his accommodation. 2. He was also discharged on a Friday, as a result of which there was little time to ensure accommodation was provided, and no proper accommodation was found for him. 3. The evidence was unclear as to whether Somewhere House routinely ensured family involvement before discharge, even where a client consented to this. 4. The evidence established the importance of discharge and accommodation arrangements in vulnerable clients such as Mr. Browning ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions.

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 ensure proper accommodation is provided before discharge

Wider context from the report

“1. Mr. Browning was discharged from Somewhere House without his family being informed of arrangements for his accommodation. 2. He was also discharged on a Friday, as a result of which there was little time to ensure accommodation was provided, and no proper accommodation was found for him. 3. The evidence was unclear as to whether Somewhere House routinely ensured family involvement before discharge, even where a client consented to this. 4. The evidence established the importance of discharge and accommodation arrangements in vulnerable clients such as Mr. Browning ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents.

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