PFD report

Paul Hardy · Prevention of Future Deaths report

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Issued 4 Feb 2015•Nottinghamshire

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
3

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 raised3

  1. Failure to act on clinical instructions to obtain and process blood and urine samples for investigation of possible urological cancer
    Part of recurring concern: Unreliable investigation and specialist referral for suspected urological cancer
  2. Failure to conduct a Significant Event Analysis when recommended
  3. Failure to act on recommendations for obtaining blood samples for INR monitoring
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 act on clinical instructions to obtain and process blood and urine samples for investigation of possible urological cancer

Wider context from the report

“1. That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer. ”

Is this part of a recurring concern?

Yes — Unreliable investigation and specialist referral for suspected urological cancer.

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 conduct a Significant Event Analysis when recommended

Wider context from the report

“3. There was a failure to act upon a clear recommendation made by the Clinical Reviewer that there should be a Significant Event Analysis of the events surrounding the death of Paul Hardy. ”

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 act on recommendations for obtaining blood samples for INR monitoring

Wider context from the report

“2. There was a failure to act upon a clear recommendation made by the Prison and Probation Ombudsman's Clinical Reviewer for facilitating the effective obtaining of blood samples for INR monitoring. ”

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