PFD report

Sally Ann Tooze Froggatt · Prevention of Future Deaths report

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Issued 11 May 2016•Preston and West Lancashire

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
4

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 raised4

  1. Failure of nursing staff to raise known risk factors with consultants
    Part of recurring concern: Failure to reliably identify and communicate individual patient risk factorsPart of recurring concern: Unreliable communication of patient-care information between clinical staff
  2. Inadequate staff training
  3. Corporate pharmacy guideline documentation contradicting NICE guidance
    Part of recurring concern: Unreliable pharmacy clinical guidance and procedures
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 of nursing staff to raise known risk factors with consultants

Wider context from the report

“4. failure of BMI nursing staff to raise known risk factors with consultants ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and communicate individual patient risk factors; Unreliable communication of patient-care information between clinical staff.

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

Inadequate staff training

Wider context from the report

“2. inadequate training of staff ”

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

Corporate pharmacy guideline documentation contradicting NICE guidance

Wider context from the report

“3. corporate pharmacy guideline documentation that appears to contradict the NICE guidance referred to in other corporate literature ”

Is this part of a recurring concern?

Yes — Unreliable pharmacy clinical guidance and procedures.

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 comply with the Duty of Candour

Wider context from the report

“1. a failure to comply with the Duty of Candour ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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