PFD report

Demi Williams · Prevention of Future Deaths report

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Issued 22 Dec 2016•Inner North London

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
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.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to consider specifically described risks during risk assessment
  2. Failure of investigations to reflect identified risk issues for further learning
    Part of recurring concern: Failure to identify and address recurring safety issues through organisational learningPart of recurring concern: Inadequate safety incident investigations
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 consider specifically described risks during risk assessment

Wider context from the report

“(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described. Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’ death could be missed. ”

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 of investigations to reflect identified risk issues for further learning

Wider context from the report

“(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described. Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’ death could be missed. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning; Inadequate safety incident investigations.

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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