PFD report

William Reid · Prevention of Future Deaths report

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Issued 30 Jun 2014•Cumbria (North & West)

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Delays in recognising deteriorating condition
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
  2. Failure to inform the GP of hospital discharge
    Part of recurring concern: Failure to reliably notify primary care of changes affecting patient carePart of recurring concern: Unreliable hospital discharge processes
  3. Delays in admission to hospital
    Part of recurring concern: Failure to provide timely hospital admission
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 30 June 2014.

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

Delays in recognising deteriorating condition

Wider context from the report

“His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration.

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 inform the GP of hospital discharge

Wider context from the report

“His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken. ”

Is this part of a recurring concern?

Yes — Failure to reliably notify primary care of changes affecting patient care; Unreliable hospital discharge processes.

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

Delays in admission to hospital

Wider context from the report

“His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken. ”

Is this part of a recurring concern?

Yes — Failure to provide timely hospital admission.

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 inform the GP of hospital admission

Wider context from the report

“His admission to hospital in 2013 was not known to his GP. The deceased was discharged from hospital without his GP being informed. There was a delay in the recognition of his deteriorating condition and in his subsequent admission to hospital. The risk is that future deaths will occur unless action is taken. ”

Is this part of a recurring concern?

Yes — Failure to reliably notify primary care of changes affecting patient care.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.

Verbatim wording from the response

“In addition, the Governments Information Strategy “The Power of Information: Putting all of us in control of the health and care information we need” was published in May 2012. A copy can be found on the GOV.UK website via the following link: The Power of Information. The Strategy sets a ten-year framework for transforming information for health and care. It aims to harness information and new technologies to achieve higher quality care and improve outcomes for patients and service users.”

Source location

2014-0288-Response-by-Department-of-Health
Page 2 · response
Published 30 June 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Establish the National Joint Registry to collect joint-replacement operation data and monitor implant performance.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 30 June 2014.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish the National Joint Registry to collect joint-replacement operation data and monitor implant performance.

Verbatim wording from the response

“Lastly, you may be interested in the work of The National Joint Registry (NJR) which was set up by the Department of Health and Welsh Government in 2002 to collect information on all hip, knee, ankle, elbow and shoulder replacement operations and to monitor the performance of joint replacement implants. The website can be found at http://www.njrcentre.org.uk/njrcentre/default.aspx.”

Source location

2014-0288-Response-by-Department-of-Health
Page 2 · response
Published 30 June 2014

Open published response
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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