9 May 2014 Lisa Webb · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Failure to use pulse oximetry in respiratory assessment View source Failure to measure and record peak flow rate View source Failure to enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation View source Failure to record respiratory and pulse rates View source Failure to avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress View source See 2 more concerns
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Lisa Webb · 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
Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyslade Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to use pulse oximetry in respiratory assessment
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyslade Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to measure and record peak flow rate
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded . There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyslade Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyslade Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to record respiratory and pulse rates
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate .
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbeyslade Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam , although it did no harm in this instance, was poor treatment for anxiety , it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress . The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” 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 Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.
Verbatim wording from the response “Action: Since Ms Webb’s death I make sure that during consultations I check the past history of significant problems and reviews, checks done and review previous consultations. I also check to see if there are any reviews outstanding and either complete them myself or ask the patient to make an appointment at reception for a review. I also record this advice within the patient’s electronic record.” Source location 2014-0213-Response-by-Basildon-Road-Surgery
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 Diazepam was prescribed because the known symptoms were not contraindicated; sleep apnoea was undisclosed and would have changed the prescribing decision.
Verbatim wording from the response “At the time I did not know that Ms Webb had sleep Apnoea. She had never indicated any symptoms to suggest that she had this condition and the symptoms she described on the day were not contraindicated with Diazepam.” Source location 2014-0213-Response-by-Basildon-Road-Surgery
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations