Recurring concern

Failure to perform clinically indicated physical examinations

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First reported 28 Feb 2014•Latest report 6 Mar 2026

Definition

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.

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: 23
Individual concerns: 23
Date range: 2014–2026
Stated actions: 31

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.

Department of Health and Social Care5

NHS England4

Recipient name withheld3

National Institute for Health and Care Excellence2

Royal College of Emergency Medicine2

Royal College of Paediatrics and Child Health2

Alexandra & Crestview Surgeries1

Ayurvedic Professionals Association1

Belmont Health Centre1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Birmingham Community Healthcare NHS Foundation Trust1

Blackpool Teaching Hospitals NHS Foundation Trust1

Bupa Care Homes1

Bupa UK Provision1

Cardiff & Vale University LHB1

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.

17 Jun2014
Manchester South
Concerns raised1
1. Failure by the GP to examine the patient’s legs
This report raised 5 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 1
1. Action
  Embed joint wound-review visits with tissue-viability specialists and general practitioners for patients with deteriorating wounds.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
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
31 Mar2014
London (East)
Concerns raised1
1. Failure to carry out directed neurological and physical observations after a fall
This report raised 4 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

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
28 Feb2014
Oxfordshire
Concerns raised1
1. Failure to undertake neurological observations and further examination after a fall
This report raised 1 other concern. 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 3
1. Action
  Review policies and procedures for managing residents after unwitnessed falls.
  Stated by Elizabeth Finn Homes LimitedStated completed
2. Action
  Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.
  Stated by Elizabeth Finn Homes LimitedStated planned
3. Action
  Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.
  Stated by Elizabeth Finn Homes LimitedStated planned
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure by the GP to examine the patient’s legs

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.1

Concerns raised1

Failure to carry out directed neurological and physical observations after a fall

Concerns raised1

Failure to undertake neurological observations and further examination after a fall

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.3

Actions described in response 1

Actions described in response 3