PFD report

John DACK · Prevention of Future Deaths report

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Issued 19 Feb 2015•London Inner (North)

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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

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Concerns raised2

  1. Failure to maintain accurate patient addresses in medical notes
    Part of recurring concern: Failure to maintain accurate patient addresses and primary-care detailsPart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Inappropriate early discharge home following MDT meetings
    Part of recurring concern: Unsafe implementation of early discharge pathways
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

    Emphasize to relevant staff the importance of accurately recording and changing patient details.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.

    Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 maintain accurate patient addresses in medical notes

Wider context from the report

“Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff of this on two separate occasions. What seems at first blush to be a relatively unimportant administrative matter can therefore have serious consequences. I heard from the surgeon treating Mr Dack that this has happened before with other patients. It seems that this part of the system of administration would benefit from review. ”

Is this part of a recurring concern?

Yes — Failure to maintain accurate patient addresses and primary-care details; Incomplete, inaccurate or unavailable clinical and care records.

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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

Inappropriate early discharge home following MDT meetings

Wider context from the report

“(No witness was able to offer any suggestions for changes to the hospital system that might prevent inappropriate early discharge home following MDT meeting on another occasion.) ”

Is this part of a recurring concern?

Yes — Unsafe implementation of early discharge pathways.

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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

Emphasize to relevant staff the importance of accurately recording and changing patient details.

Verbatim wording from the response

“Our investigation has concluded that the ward clerk was told to change Mr Dack’s address by the patient’s nurse. A mistake was made however as she recorded him as being of ‘no fixed abode’. We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so.”

Source location

2015-0151-Response-by-Barts-Health-NHS
Page 1 · response
Published 19 February 2015

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.

Verbatim wording from the response

“Your concern was that Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff.”

Source location

2015-0151-Response-by-Barts-Health-NHS
Page 1 · response
Published 19 February 2015

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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