PFD report

Amanda Susan Harris · Prevention of Future Deaths report

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Issued 10 Jun 2015•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
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

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Concerns raised3

  1. Failure to ensure doctor assessment before discharge from the Minor Injuries Unit
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to assess injury-related immobility and its effects when arranging fracture clinic appointments
    Part of recurring concern: Unreliable care and follow-up for identified fractures
  3. Failure to consider anticoagulant therapy
    Part of recurring concern: Unsafe anticoagulant management
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 ensure doctor assessment before discharge from the Minor Injuries Unit

Wider context from the report

“That Mrs Harris was not seen by a doctor before leaving the Minor Injuries Unit, that anticoagulant therapy was not considered and that when fixing an appointment for the fracture clinic the potential immobility from the injury and the effects of that immobility were not assessed. ”

Is this part of a recurring concern?

Yes — 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

Failure to assess injury-related immobility and its effects when arranging fracture clinic appointments

Wider context from the report

“That Mrs Harris was not seen by a doctor before leaving the Minor Injuries Unit, that anticoagulant therapy was not considered and that when fixing an appointment for the fracture clinic the potential immobility from the injury and the effects of that immobility were not assessed. ”

Is this part of a recurring concern?

Yes — Unreliable care and follow-up for identified fractures.

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 consider anticoagulant therapy

Wider context from the report

“That Mrs Harris was not seen by a doctor before leaving the Minor Injuries Unit, that anticoagulant therapy was not considered and that when fixing an appointment for the fracture clinic the potential immobility from the injury and the effects of that immobility were not assessed. ”

Is this part of a recurring concern?

Yes — Unsafe anticoagulant management.

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