Recurring concern

Failure to perform clinically indicated physical examinations

First to latest report 28 Feb 2014 — 6 Mar 2026

Reports that mention this concern
23
Times this concern has been raised
23
Stated actions linked to this concern
31

What this concern includes

Includes failures of the clinical physical-examination process where an indicated examination is omitted, incomplete, inadequately adapted to the patient or circumstances, or based on an unsafe substitute such as absence of reported pain; include relevant examination components such as vascular, limb, top-to-toe, internal or home-visit examinations.

What is not included
  • Excludes diagnostic imaging, laboratory testing or treatment failures where no physical-examination deficiency is identified.
  • Excludes failures limited to recording, communicating or escalating examination findings when the examination itself was completed adequately.
  • Excludes generic clinical assessment or diagnostic reasoning deficiencies that do not specifically concern performing or completing a clinically indicated physical examination.
  • Excludes factual pain, DVT or other hazard assertions without an identified failure in the physical-examination process.

Reports and published responses 23 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    AUDREY VERA GARLAND · 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

    Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.

    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 by the GP to examine the patient’s legs

    Wider context from the report

    “4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs. ”

    Source location

    AUDREY VERA GARLAND · Prevention of Future Deaths report
    Page 2 · 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

    Embed joint wound-review visits with tissue-viability specialists and general practitioners for patients with deteriorating wounds.

    Verbatim wording from the response

    “Any ulcer that fails to improve or deteriorates and there is an issue of noncompliance is highlighted using the organisation’s untoward incident system. Joint visits with other health care professionals such as the Specialist Tissue Viability Advisor and General Practitioners to review patients with deteriorating wounds are now embedded into practice within the team.”

    Source location

    2014-0271-Response
    Page 2 · response
    Published 17 June 2014

    Open published response

  2. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 carry out directed neurological and physical observations after a fall

    Wider context from the report

    “2. The staff at the care home accepted the responsibility of Mr Godfrey’s care following the paramedic’s assessment. They agreed to observe Mr Godfrey during the night. The actual checks carried out by the staff were not in accordance with the direction given by the paramedic. The senior care worker confirmed that she did not examine the swelling or check for alertness. 3. The Deputy Manager who gave evidence at the inquest confirmed that the checks carried out by the staff were not in her view appropriate. She would have expected the pupils to have been checked and checks to ensure that the patient was alert and orientated. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Oxfordshire

    AI-generated summary

    Peter Norman Nott · 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

    Peter Norman Nott, who had Parkinson's disease and was at very high risk of falls, experienced an unwitnessed fall at a nursing home on 2 September 2013 and died on 8 September 2013 from a subdural haemorrhage and Parkinson's disease. The concerns included that neurological observations after the fall were not undertaken beyond a simple visual examination and that inaccurate information about his consciousness was passed to paramedics.

    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 neurological observations and further examination after a fall

    Wider context from the report

    “Although staff at the care home were attentive to Dr Norman Nott after his fall, and advice was sought from Dr Norman Nott’s GP, it was accepted in questioning that the trained staff should have undertaken neurological observations over and above a simple visual examination. The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon. ”

    Source location

    Peter Norman Nott · Prevention of Future Deaths report
    Page 2 · 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

    Review policies and procedures for managing residents after unwitnessed falls.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    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

    Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    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

    Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.

    Verbatim wording from the response

    “This procedure will be reinforced during staff meetings and any individual training needs will be monitored through the supervision, learning and development programme. Basic competencies for head injury care will be reviewed with all clinical staff and the person in charge of our residential home.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026