PFD report

Walter Willows · Prevention of Future Deaths report

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Issued 10 Jun 2015•Manchester South

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

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Concerns and recipient responses

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Concerns raised1

  1. Infrequent review of feeding regimes in care plans
    Part of recurring concern: Unreliable care-planning processes
Responses linked to these concerns

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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

Infrequent review of feeding regimes in care plans

Wider context from the report

“During the course of the inquest hearing I was told, inter alia, that the Care Plans for such clients were reviewed on a three monthly basis. This included their specific feeding regimes. In the case of Mr Willows it was apparent that this should have been looked at far more frequently so as to adjust his diet to suit his swallowing ability. I took the view that these plans (and especially that part relating to feeding) should be examined more frequently and it was within the power of yourselves to arrange for this to happen. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning 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