Recurring concern

Failure to ensure complete clinical history and examination

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First reported 23 Oct 2013•Latest report 18 Dec 2025

Definition

What this concern includes

Includes failures in clinical assessment arrangements that leave required history-taking or physical examination incomplete, omitted, inadequately performed or insufficiently assured, including failures of competence assurance and failures involving specific examination components when they form part of the broader history-and-examination standard.

Not included

Excludes failures limited to recording, communicating or reviewing clinical information when the underlying history and examination were completed adequately.
Excludes condition-specific assessment pathways, diagnostic tests and treatment decisions where complete history-taking or physical examination is not the shared unsafe condition.
Excludes generic staffing, training or governance deficiencies unless they directly concern clinicians' ability or assurance to perform complete clinical history and examination.
Excludes the existing narrower concerns concerning incomplete clinical history-taking or clinically indicated physical examinations when an assertion is confined solely to one of those components and does not support the broader combined condition.

Reports: 4
Individual concerns: 4
Date range: 2013–2025
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Beckenham Beacon Urgent Care Centre1

Bromley Healthcare Community Interest Company1

Cator Medical Centre1

Department of Health and Social Care1

General Medical Council1

Joint Royal Colleges Ambulance Liaison Committee1

National Institute for Health and Care Excellence1

NHS England1

NHS Greater Manchester Integrated Care Board1

NHS South East London Integrated Care Board1

Partnering Health Limited1

Royal College of Emergency Medicine1

Royal College of General Practitioners1

Royal College of Paediatrics and Child Health1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Dec2025
Hampshire, Portsmouth Southampton
Concerns raised1
1. Failure of Urgent Care Centres to provide doctor examination
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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 linked to these concerns in the published data.
AI-generated summary

Shre Kumar CHATTERJEE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shre Chatterjee developed a sudden severe headache in August 2023 and died at University Hospital Southampton on 12 October 2023 from an acute on chronic subdural haematoma. The report identifies repeated unsuccessful attempts to obtain timely face-to-face medical assessment, including missed opportunities to refer him for hospital assessment and a CT scan. It also raises concern that out-of-hours and 111 doctors could not directly book urgent appointments with some GP surgeries.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of Urgent Care Centres to provide doctor examination
Wider context from the report
“During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”
Source location
Shre Kumar CHATTERJEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Jun2025
Manchester South
Concerns raised1
1. Insufficient understanding of how to listen for heart defects during the 6-8 week GP check
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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 linked to these concerns in the published data.
AI-generated summary

Esme Vera Louise Atkinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient understanding of how to listen for heart defects during the 6-8 week GP check
Wider context from the report
“2. The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking all of the right questions and a good understanding of how to listen for such a heart defect. ”
Source location
Esme Vera Louise Atkinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Mar2023
Surrey
Concerns raised1
1. Failure to undertake a detailed history and full neurological examination in general practice
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
  Stated by NHS EnglandStated planned
2. Action
  Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
  Stated by National Institute for Health and Care ExcellenceStated completed
Respondent positions 4
1. Position
  NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Existing national guidance is considered sufficient for managing febrile seizures.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
3. Position
  RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
  Stated by Royal College of Emergency MedicineUnable to act
AI-generated summary

Louis James Rogers · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake a detailed history and full neurological examination in general practice
Wider context from the report
“4. General Practice - At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken. ”
Source location
Louis James Rogers · Prevention of Future Deaths report
Page 3 · concerns
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
Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.

Verbatim wording from the response
“As a result of your Report, we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.”

Source location
Response from NHS England
Page 3 · response
Published 31 March 2023
Open published response
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
Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.

Verbatim wording from the response
“We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).”

Source location
Response from NICE
Page 1 · response
Published 31 March 2023
Open published response
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
NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.

Verbatim wording from the response
“The National Institute for Health and Care Excellence (NICE) are responsible for producing clinical guidance for health and care practitioners on the issue of febrile seizures. Their guidance on Epilepsies in children, young people and adults (NG127) covers the diagnosis, treatment and management, referral recommendations and information and support for the management of epilepsy and seizures in children:”

Source location
Response from NHS England
Page 1 · response
Published 31 March 2023
Open published response
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
Existing national guidance is considered sufficient for managing febrile seizures.

Verbatim wording from the response
“NHS England has been sighted on the response to your Report from NICE, who have advised that there is sufficient national guidance regarding the management of febrile seizures.”

Source location
Response from NHS England
Page 2 · response
Published 31 March 2023
Open published response
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
Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.

Verbatim wording from the response
“We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).”

Source location
Response from NICE
Page 1 · response
Published 31 March 2023
Open published response
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
RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.

Verbatim wording from the response
“RCEM would be happy to work with NHS England / National Institute for Healthcare Excellence, Royal Colleges and other interested parties to help develop further evidence based or consensus guidance in this complex area of clinical practice. We are mindful that this would be a significant undertaking and that it would therefore not be appropriate for RCEM to take the lead on such a project.”

Source location
Response from Emergency Care Committee
Page 1 · response
Published 31 March 2023
Open published response
23 Oct2013
Inner South London
Concerns raised1
1. Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The doctor disputed that fully undressing and examining every painful calf in prone and supine positions reflected common general practice.
  Stated by NHS EnglandDisputes the concern
AI-generated summary

Jacqueline Allwood · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination
Wider context from the report
“(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients. ”
Source location
Jacqueline Allwood · Prevention of Future Deaths report
Page 7 · concerns
Open source report
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 doctor disputed that fully undressing and examining every painful calf in prone and supine positions reflected common general practice.

Verbatim wording from the response
“2.4. ████████ was criticised for his incomplete examination of Mrs Allwoods leg. ████████ was surprised that the expert GP witness stated that all patients with a painful calf should remove their lower clothing (except for underwear) and be examined in the prone and supine position on the examination couch. ████████ did not feel this was common GP practice and wasn’t sure that all patients would accept this exposure in a GP surgery situation. However he accepted that he should have removed Mrs Allwoods shoes and socks so he had full exposure of Mrs Allwoods lower leg. He also accepts that he should have measured the calf diameter, if for no other reason than to be helpful should the patient present for a second time and this measurement could be used as a comparator⁷.”

Source location
2013-0275-Response-by-NHS-England
Page 7 · response
Published 27 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of Urgent Care Centres to provide doctor examination

Concerns raised1

Insufficient understanding of how to listen for heart defects during the 6-8 week GP check

Concerns raised1

Failure to undertake a detailed history and full neurological examination in general practice

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 4

Respondent positions 1