PFD report

Daniel Gary Dunkley · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 2 May 2017•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
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 conduct referred full mental health assessments
  2. Failure to notify relevant staff and patients of scheduled mental health assessments
    Part of recurring concern: Failure to complete timely direct mental health assessments after referral
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 conduct referred full mental health assessments

Wider context from the report

“During the course of the evidence it became clear that prior to Mr Dunkley's death three referrals were made for him to undergo a full mental health assessment. None of the assessments took place prior to his death. The assessment due on the morning that he was found hanging in his cell was never notified to House Unit 2 or indeed to Mr Dunkley. Such assessments are vital to keep those suffering from psychiatric problems to be kept safe and an urgent review of the whole process is necessary. ”

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 to notify relevant staff and patients of scheduled mental health assessments

Wider context from the report

“During the course of the evidence it became clear that prior to Mr Dunkley's death three referrals were made for him to undergo a full mental health assessment. None of the assessments took place prior to his death. The assessment due on the morning that he was found hanging in his cell was never notified to House Unit 2 or indeed to Mr Dunkley. Such assessments are vital to keep those suffering from psychiatric problems to be kept safe and an urgent review of the whole process is necessary. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral.

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