Concerns raised 1
Blocking of direct booking with a patient's own GP for face-to-face assessment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Blocking of direct booking with a patient's own GP for face-to-face assessment
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
Open source report
4 Jul 2025 Daniel Norman Hatchett · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Insufficient GP appointment time for holistic review of patients with chronic disease View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Daniel Norman Hatchett · 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
Daniel Norman Hatchett had declining physical and mental health, including stress alongside chronic health conditions. In the early hours of 9 November 2024, he was found hanging at home and pronounced dead at the scene; the circumstances were deemed non-suspicious. The report identified missed opportunities for mental health follow-up and therapy, and concerns about chronic disease reviews not adequately addressing patients’ mental health, particularly where men may not disclose concerns without being asked directly.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient GP appointment time for holistic review of patients with chronic disease
Wider context from the report “2. GP appointment timings are often insufficient for the necessary holistic review of this cohort of patients.
” Source location Daniel Norman Hatchett · Prevention of Future Deaths report
Open source report
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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 General practices are responsible for operating arrangements, including individual appointment duration and addressing patients’ physical and mental health needs.
Verbatim wording from the response “As clinical professionals, we expect that GPs conduct their appointments with sufficient time to address their patients’ needs and to appropriately assess any health concerns. General Practices are independent businesses and are therefore responsible for the way they operate, including the duration of individual appointments. This framework allows GPs to appropriately identify both physical and mental health issues, ensure thorough assessment, and provide timely interventions or referrals where necessary.” Source location Response from Department for Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appointment time constraints mean clinicians often rely on patients and families to disclose mental health problems rather than proactively identifying them.
Verbatim wording from the response “As clinicians we will aim to do better and ask open-ended questions about alcohol use, stress and low mood as much as possible but we realise the time constraints on us means we often rely on the patient & families to alert us about these problems.” Source location Response from Department for Health and Social Care
Open published response
10 Jun 2025 Andrew James CONNOLLY · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew James CONNOLLY · 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
Andrew James Connolly died after being struck by a train having entered the track at a railway station on 26 November 2024. Concerns included telephone GP appointments despite his mental health not improving, no opportunity for family input into his clinical assessment, and a lack of guidance or mechanism for these arrangements; the inquest heard that his risk was not recognised.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice
Wider context from the report “The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health. The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information.
The consequence of these two factors was that his risk was not recognised.
On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations.
” Source location Andrew James CONNOLLY · Prevention of Future Deaths report
Open source report
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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 Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.
Verbatim wording from the response “Having reflected on the contents of your report, I do think it is important for our GP practices to ensure that the best options for appointments are provided for patients recognising both their preferences but also an individual’s clinical assessment of their condition and needs. In response to this report, I will ensure that NHS GM produces an advice briefing for our GPs and practices to be distributed through our primary care networks, that:” Source location 2025-0290 - Response from Greater Manchester ICB
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone and online consultations remain appropriate for many patients, depending on their clinical circumstances; face-to-face appointments are not universally required.
Verbatim wording from the response “GPs in Greater Manchester provide a range of appointment options to meet patient need. This does involve both face to face appointments as well as telephone and online consultations, all of which can meet patient need depending on the circumstances.” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
6 Jun 2025 Esme Vera Louise Atkinson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ask all appropriate questions during the 6-8 week GP check View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ask all appropriate questions 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
Open source report
7 Jul 2023 Christopher Howard SMITH · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of robust GP clinical assessments for prisoners View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Christopher Howard SMITH · 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
Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of robust GP clinical assessments for prisoners
Wider context from the report “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care
I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment.
Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.
There was a lack of robust GP visits , despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments . Again, this is unsafe.
There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place.
” Source location Christopher Howard SMITH · Prevention of Future Deaths report
Open source report
28 Apr 2022 Alphonso Alexander Shearer · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to provide face-to-face GP assessment when deterioration may be present View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Greater Manchester Integrated Care Board North Trafford Group Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
North Trafford Group Practice
Review systems for recording and prioritising consultation and home-visit requests.
View source
North Trafford Group Practice
Remind reception staff to record every home-visit request in the clinical system for clinician assessment.
View source
North Trafford Group Practice
Reinforce home-visit request recording requirements through reception staff orientation and training.
View source
NHS Greater Manchester Integrated Care Board
Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
View source
NHS Greater Manchester Integrated Care Board
Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
View source See 2 more actions
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AI-generated summary
Alphonso Alexander Shearer · 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
Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide face-to-face GP assessment when deterioration may be present
Wider context from the report “3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.
” Source location Alphonso Alexander Shearer · Prevention of Future Deaths report
Open source report
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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 Review systems for recording and prioritising consultation and home-visit requests.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
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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 Remind reception staff to record every home-visit request in the clinical system for clinician assessment.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
Open published response
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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 Reinforce home-visit request recording requirements through reception staff orientation and training.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
Open published response
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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 Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
Verbatim wording from the response “• Greater Manchester integrated care system has completed an action plan with further steps to support improved access and address healthcare inequalities. The plan includes how each of our 10 local systems will tackle variation in general practice, which is our utmost priority. This will continue to be progressed following the establishment of NHS Greater Manchester Integrated Care and the closure of local clinical commissioning groups on 1 July:” Source location Response from NHS Greater Manchester
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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 Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
Verbatim wording from the response “• In October 2021, NHS England set out a plan for improving access for patients and supporting general practice. This sets out how we will increase and optimise capacity, address variation, encourage good practice, and improve access, including face-to-face appointments with GPs.” Source location Response from NHS Greater Manchester
Open published response
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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 Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.
Verbatim wording from the response “The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit.” Source location Response from Tafford Clinical Commissioning Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.
Verbatim wording from the response “Alongside this we are also working with the Care Quality Commission (CQC), which will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting reasonable needs of patients. The CQC is rapidly developing an inspection methodology with a particular focus on access to GP services.” Source location Response from NHS Greater Manchester
Open published response
6 Sep 2021 Mark Holden · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to provide physical examination during telephone GP consultations where clinically needed View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mark Holden · 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
Mark Thomas Holden was diagnosed with Covid-19 and subsequently developed a deep vein thrombosis in his left calf, which led to a pulmonary embolus. He collapsed at home on 26 February 2021 and attempts to resuscitate him were unsuccessful. Concerns included the lack of a face-to-face GP examination, failure of the electronic system to alert staff to a markedly raised D-Dimer, and NICE guidance not addressing Covid-19-related clotting risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide physical examination during telephone GP consultations where clinically needed
Wider context from the report “1. The appointment with the GP was via telephone due to Covid. As a result, there was no examination of Mr Holden and no opportunity to identify the DVT which was present at the time of the telephone consultation .
” Source location Mark Holden · Prevention of Future Deaths report
Open source report
24 Aug 2021 Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of GP consultation arrangements to support effective communication about deteriorating health View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England NHS Greater Manchester Integrated Care Board Tameside Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
View source
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Discuss negative patient feedback with relevant practices to support learning and improvement.
View source
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
View source
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
View source See 1 more action
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AI-generated summary
Stanislaw Wieslaw ZIELINSKI · 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
Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of GP consultation arrangements to support effective communication about deteriorating health
Wider context from the report “1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of telephone consultations. The inquest heard that he and his family struggled to communicate with the GP to explain his deteriorating health position as a result of how his GP practice was delivering health care . The inquest heard evidence that as a consequence his deteriorating picture was not fully understood by his GP and he was additional anxious as a result of an inability to express his concerns in person.
” Source location Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report
Open source report
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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 Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
Verbatim wording from the response “Work is also ongoing to understand negative patient experiences of primary care so that we can mitigate and reduce similar incidents going forward by sharing the learning across all general practices within Tameside and Glossop. This work involves reviewing appointment data on a” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
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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 Discuss negative patient feedback with relevant practices to support learning and improvement.
Verbatim wording from the response “monthly basis in conjunction with any feedback from patients highlighting poor experiences. We then have conversations with practices regarding those poor experiences to support learning and improvement across all general practice within Tameside and Glossop. As such we encourage all patients to share their experiences – positive as well as negative – to reduce any inequality of access.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
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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 Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
Verbatim wording from the response “As part of the planned update to Locally Commissioned Services, delivered by general practice, and to further support practice reflection on whether each individual practice has the appropriate blend of face to face and telephone consultations for their individual patient lists, from 1 October 2021, practices will survey their patients and clinicians every six months to understand how both parties experience delivering primary care during the ongoing and evolving pandemic. Tameside and Glossop CCG has been working to improve patient experience and access throughout the pandemic and will implement an action plan as part of this work that will also respond to the concerns raised by this Prevention of Future Deaths letter. Due to the nature of the available data this will be a rolling, ongoing action plan involving continual review of data and experiences.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
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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 Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
Verbatim wording from the response “As part of the planned update to Locally Commissioned Services, delivered by general practice, and to further support practice reflection on whether each individual practice has the appropriate blend of face to face and telephone consultations for their individual patient lists, from 1 October 2021, practices will survey their patients and clinicians every six months to understand how both parties experience delivering primary care during the ongoing and evolving pandemic. Tameside and Glossop CCG has been working to improve patient experience and access throughout the pandemic and will implement an action plan as part of this work that will also respond to the concerns raised by this Prevention of Future Deaths letter. Due to the nature of the available data this will be a rolling, ongoing action plan involving continual review of data and experiences.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
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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 National general practice guidance required remote triage and face-to-face appointments where clinically appropriate, addressing concerns about remote-only care.
Verbatim wording from the response “Since the advent of the Covid-19 pandemic general practice has been delivering health care services according to the national General Practice in the Context of Coronavirus Standard Operating Procedure that has been regularly updated. This national guidance was in force at the time of Mr Zielinski’s death. The aim of this Standard Operating Procedure was to ensure general practice was able to provide health care to patients in a safe environment, limiting the opportunity of Covid-19 infections in staff and patients while reducing the number of absences either by infections or self-isolation.” Source location 2021-0277-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Open published response
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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 The CCG cannot determine how GP consultations are undertaken because it lacks legal powers and is not party to the nationally negotiated contract.
Verbatim wording from the response “Nonetheless, whilst the CCG seeks to raise and maintain high standards it has no legal powers to determine how such consultations are undertaken. The contract with GPs – which is negotiated nationally and which the CCG isn’t actually a party to – doesn’t allow for specifying how consultations are delivered. At best the CCG can share data, share best practice and share any negative feedback with practices to understand why it has been received and encouraging changes that may want to consider to improve patient care and/or lived experience.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
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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 Existing guidance, procedures and resources are considered sufficient to support safe remote general practice consultations alongside face-to-face appointments.
Verbatim wording from the response “Throughout the pandemic, NHS England and NHS Improvement (NHSEI) provided guidance to general practice and continually updated standard operating procedures to ensure that changing services could operate safely. NHSEI set out clear expectations that general practices offer face to face appointments alongside remote appointments (telephone and online), and that clinical appropriateness and patient preference should be taken into account to determine the most appropriate consultation method. NHSEI has also supported general practices in how best to” Source location 2021-0277-Response-from-Department-of-Health-Social-Care_Published.pdf
Open published response
23 Aug 2021 Maurice Leech · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to provide physical examination during GP consultations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Maurice Leech · 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
Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.
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 provide physical examination during GP consultations
Wider context from the report “1. The inquest heard evidence that pre Covid Mr Leech would have been examined face to face by the GP rather than a telephone consultation without an examination . The evidence indicated that a physical examination would probably have resulted in Mr Leech being referred back to hospital at an earlier stage.
” Source location Maurice Leech · Prevention of Future Deaths report
Open source report
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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 Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
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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 Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.
Verbatim wording from the response “Professional guidance published by the General Medical Council sets out high level principles of good practice expected of everyone when consulting and or prescribing remotely for the patient https://www.gmc-uk.org/ethical-guidance/learning-materials/remote-prescribing-high-level-principles and guidance to support shared decision making https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent.” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.
Verbatim wording from the response “Throughout the pandemic, NHSEI provided guidance to general practice and continually updated standard operating procedures to ensure that changing services could operate safely. NHSEI set out clear expectations that general practices offer face to face appointments alongside remote appointments (telephone and online), and that clinical appropriateness and patient preference should be taken into account to determine the most appropriate consultation method. NHSEI has also supported general practices in how best to communicate with their population on how to access services. Further details on guidance and standard operating procedures can be found on the NHSEI website¹.” Source location 2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
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4 Jan 2021 Pardeep Singh PLAHE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Ashfield Surgery EMIS Group NHS Birmingham and Solihull Integrated Care Board NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Ashfield Surgery
Update the induction pack with EMIS appointment-screen guidance and disseminate it to new staff, nursing staff, locums and relevant Primary Care Networks.
View source
Ashfield Surgery
Use manual log-off and log-on refreshing as a workaround to identify newly added appointments and prevent missed appointments.
View source
EMIS Group
Update and disseminate appointment-refresh self-help guidance through the customer portal and EMIS Web information feed.
View source
EMIS Group
Issue Safety Advisory Notice SAN 2021-005 to GP Practices and Clinical Services about the appointment-refresh risk and required actions.
View source
EMIS Group
Develop an automated appointment-book refresh solution for current-day appointments and inactive user sessions.
View source
EMIS Group
Roll out the completed appointment-refresh functionality to all users through controlled implementation and effectiveness and performance checks.
View source
NHS England
Issue a Safety Advisory Notice to GP practices and clinical services setting out required actions and further information.
View source
NHS Birmingham and Solihull Integrated Care Board
Send all GP practices information about appointment-refresh risks, resolution steps and IT support contacts.
View source See 5 more actions
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AI-generated summary
Pardeep Singh PLAHE · 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
Pardeep Singh Plahe died at Queen Elizabeth Hospital on 12 August 2020 after inflicting a catastrophic injury to his neck with a decorative samurai sword. He had been increasingly concerned about a physical health complaint and had a scheduled GP telephone consultation that was missed because of a technical problem with the EMIS system. The report raised concerns that consultation lists could fail to update, creating a risk that urgent telephone consultations might be missed, and that the identified mitigation depended on practitioners remembering to log out and back in to the system.
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 the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update . Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment .
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” Source location Pardeep Singh PLAHE · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the induction pack with EMIS appointment-screen guidance and disseminate it to new staff, nursing staff, locums and relevant Primary Care Networks.
Verbatim wording from the response “I have enclosed our Induction Pack, which Page 4 highlights the issues with EMIS and the steps that we take at Ashfield Surgery to address this. This is to ensure that all new members of staff are aware of this. We have also discussed this with our nursing staff and our long-term locums. This information has also been shared with our Primary Care Networks that use EMIS currently, following the Coroners case.” Source location 2021-0061-Response-from-Ashfield-Surgery-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use manual log-off and log-on refreshing as a workaround to identify newly added appointments and prevent missed appointments.
Verbatim wording from the response “Outcome
Manually need to log on and off as refresh the screening isn’t reliable to ensure appointments not missed.” Source location 2021-0061-Response-from-Ashfield-Surgery-Redacted
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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 Update and disseminate appointment-refresh self-help guidance through the customer portal and EMIS Web information feed.
Verbatim wording from the response “• A user-facing article has been posted on the EMIS Customer portal to ensure they know to mitigate the risk and is available for self-help (KB0064144) to all customers: “Why isn’t my Appointment Book refreshing?” The article was originally published before this incident (07/02/2020) and updated further on 22/12/2020.” Source location 2021-0061-Response-from-EMIS-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue Safety Advisory Notice SAN 2021-005 to GP Practices and Clinical Services about the appointment-refresh risk and required actions.
Verbatim wording from the response “2. A Safety Advisory Notice (SAN 2021-005) advising organisation and users of the issue, the actions that need to be completed, and a link to direct them to further information if required was sent out to all GP Practices and Clinical Services on 3 February 2021.” Source location 2021-0061-Response-from-EMIS-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an automated appointment-book refresh solution for current-day appointments and inactive user sessions.
Verbatim wording from the response “3. The development of a solution to mitigate the risk to all GP Practices and Clinical Services using the appointment book functionality is underway. This is estimated to be released early Q2 2021, this will:” Source location 2021-0061-Response-from-EMIS-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the completed appointment-refresh functionality to all users through controlled implementation and effectiveness and performance checks.
Verbatim wording from the response “• Once completed, the functionality will be rolled out to all users in a controlled manner, to ensure it meets effectiveness and performance metrics. This approach is in line with usual processes for changes to functionality to ensure clinical safety and system performance is maintained.” Source location 2021-0061-Response-from-EMIS-Redacted
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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 Issue a Safety Advisory Notice to GP practices and clinical services setting out required actions and further information.
Verbatim wording from the response “• A Safety Advisory Notice (SAN) was sent out to all GP Practices and Clinical Services on 3 February 2021, advising organisations and users of the issue, the actions that need to be completed, and a link to direct them to further information if required.” Source location 2021-0061-Response-from-NHS-England-and-NHS-Improvement-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send all GP practices information about appointment-refresh risks, resolution steps and IT support contacts.
Verbatim wording from the response “The most recent position has been checked by the CCG’s IT Team in light of your report, and I am advised that with the upgrade to Windows 10 there have been a number of reports to EMIS of this problem reoccurring. In response to this information, the CCG has sent a communication to all GP practices highlighting potential problems and providing information on how this can be resolved, as well as providing them with contact details for the IT support service so that they can access assistance on resolving any ongoing problems. In addition, EMIS issued a safety advisory notice on 3rd February to alert practices to the need to identify and address this issue.” Source location 2021-0061-Response-from-CCG-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Manual Appointment Refresh is currently sufficient; users do not need to log out and back into EMIS while automatic refresh is developed.
Verbatim wording from the response “• There is no need for users to log out and log into EMIS Web. The current advice is to use the ‘Appointment Refresh’ function whilst an automatic capability is developed and released.” Source location 2021-0061-Response-from-EMIS-Redacted
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.