PFD report

Stephen Thomas BARTON · Prevention of Future Deaths report

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Issued 1 Oct 2021•Staffordshire 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. Lack of tracking systems for non-cancer outpatient appointments
    Part of recurring concern: Unreliable tracking and follow-up of outpatient appointments
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

Lack of tracking systems for non-cancer outpatient appointments

Wider context from the report

“Stephen missed numerous out-patient appointments. I heard expert evidence from a hospital consultant indicating that in the great majority of cases there is no way of tracking out-patient appointments in the NHS. This is however done in cancer cases. The consultant felt it should not be too difficult to develop a system of tracking out-patient appointments in non-cancerous cases. If realistically this could be introduced it might well save a lot of administrative time and indeed prevent unnecessary deaths. ”

Is this part of a recurring concern?

Yes — Unreliable tracking and follow-up of outpatient appointments.

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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