PFD report

Grace Mary Bates · Prevention of Future Deaths report

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Issued 7 Jan 2014•North London

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

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 raised1

  1. Unavailability of a specialist diabetic nurse at the hospital over weekends
    Part of recurring concern: Unreliable diabetes care and management
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

    Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 January 2014.

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

  1. Position

    Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Unavailability of a specialist diabetic nurse at the hospital over weekends

Wider context from the report

“(1) That should be a specialist diabetic nurse available over the weekend at the hospital. ”

Is this part of a recurring concern?

Yes — Unreliable diabetes care and management.

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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

Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.

Verbatim wording from the response

“Our Head of Diabetes & Endocrinology; Business Manager for Diabetes and our Lead Diabetes Nurse submitted a business case for the approval for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week.”

Source location

2014-0007-Response
Page 1 · response
Published 7 January 2014

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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

Local healthcare organisations are responsible for assessing needs and commissioning and delivering safe diabetes services, including appropriate nursing staff.

Verbatim wording from the response

“Local organisations are best placed to assess the needs of their populations, and to commission and deliver high-quality, safe and comprehensive diabetes services; including appropriate nursing staff and I expect local healthcare organisations to do their utmost to deliver care against NICE standards as part of a general duty to ensure continuous improvement in quality.”

Source location

2014-0007-Response-2
Page 2 · response
Published 7 January 2014

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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.2

  1. 1

    Use incentives, rewards and sanctions, including the NHS Standard Contract, with strategic partners to support adoption of all clinical standards.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 7 January 2014.
  2. 2

    Attach the Seven Days a Week clinical standards to disseminate expectations for consistent urgent and emergency care.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 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

Use incentives, rewards and sanctions, including the NHS Standard Contract, with strategic partners to support adoption of all clinical standards.

Verbatim wording from the response

“NHS England’s ambition is for all the clinical standards to be adopted in every community in England by the end of 2016/17. With a number of our key strategic partners, we will use a range of incentives, rewards and sanctions, including the NHS Standard Contract, to support the change.”

Source location

2014-0007-Response-2
Page 2 · response
Published 7 January 2014

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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

Attach the Seven Days a Week clinical standards to disseminate expectations for consistent urgent and emergency care.

Verbatim wording from the response

“The clinical standards are attached for your convenience and further information about the work of the forum can be found at http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/”

Source location

2014-0007-Response-2
Page 2 · response
Published 7 January 2014

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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