Recipient

Air Balloon Surgery

First report 17 Jun 2022•Latest report 17 Jun 2022

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 12

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Air Balloon Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

17 Jun2022
Avon
Concerns raised2
1. Failure to disclose incident investigations and related documents to the Coroner’s office
2. Inadequate investigation of incidents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Undertake a root cause analysis with detailed risk assessment to identify safety actions.
  Stated completed
2. Action
  Review the new significant event analysis system at the practice board meeting after its further use in August.
  Stated planned
3. Action
  Complete a second significant event analysis using the revised investigation system.
  Stated completed
1. Action
  Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.
  Stated completed
2. Action
  Produce and use a new significant event analysis policy and documentation process for future investigations.
  Stated completed
Respondent positions 1
1. Position
  Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.
  Existing arrangements considered sufficient
AI-generated summary

Donald Gore · 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

Donald Gore acquired a Mycobacterium Chimaera infection during open-heart surgery in November 2016 and died after a prolonged delay in diagnosis. The report describes failures to communicate and recognise the infection risk, delays in testing, and treatment for misdiagnosed sarcoidosis. It also raises concerns that the investigation into the incident was inadequate and was not disclosed to the Coroner’s office.

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. The report was sent to Air Balloon Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to disclose incident investigations and related documents to the Coroner’s office
Wider context from the report
“The evidence demonstrated that the General Practitioner to whom Mr Gore first presented with symptoms on 3.11.17 did not read the alert regarding the risk of Mycobacterium Chimaera infection contained in his GP records, entered in March 2017 further to a letter sent to the practice by the cardiac surgery department. The investigation in response to this is summarised in a document headed “Proforma for completion at SEA/adverse incident meeting” dated 14.1.19. My concerns are - 1. The investigation in response to this incident summarised in that document – a) Does not conform to the usual detail and format of such investigations (eg a Root Cause Analysis), and b) Appeared inadequate; (In addition the investigation and document, or even their existence, were not disclosed to the Coroner’s office despite three GP statements/reports from your practice being requested and provided in the preparation for the Inquest, only being revealed in the course of oral evidence from the GP during the course of the Inquest). ”
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 Air Balloon Surgery; that does not assign responsibility.
PFD Monitor interpretation
Inadequate investigation of incidents
Wider context from the report
“The evidence demonstrated that the General Practitioner to whom Mr Gore first presented with symptoms on 3.11.17 did not read the alert regarding the risk of Mycobacterium Chimaera infection contained in his GP records, entered in March 2017 further to a letter sent to the practice by the cardiac surgery department. The investigation in response to this is summarised in a document headed “Proforma for completion at SEA/adverse incident meeting” dated 14.1.19. My concerns are - 1. The investigation in response to this incident summarised in that document – a) Does not conform to the usual detail and format of such investigations (eg a Root Cause Analysis), and b) Appeared inadequate; (In addition the investigation and document, or even their existence, were not disclosed to the Coroner’s office despite three GP statements/reports from your practice being requested and provided in the preparation for the Inquest, only being revealed in the course of oral evidence from the GP during the course of the Inquest). ”
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
Undertake a root cause analysis with detailed risk assessment to identify safety actions.

Verbatim wording from the response
“2. Undertaken a Root Cause Analysis – attached. This has included a detailed risk assessment showing how rare this infection is and has helped to identify actions for the surgery.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
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
Review the new significant event analysis system at the practice board meeting after its further use in August.

Verbatim wording from the response
“6. The surgery has used this new system for the repeat SEA conducted on this case on the 18th July 2022. Attached. We will continue to use it for a further SEA meeting planned in August, where other SEA issues are being discussed. The practice board will then review at its meeting in August to assess if it is fit for purpose.”

Source location
Response from Air Balloon Surgery
Page 4 · response
Published 20 September 2022
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
Complete a second significant event analysis using the revised investigation system.

Verbatim wording from the response
“3. Additionally, the surgery has completed a second SEA process on the 18th July 2022 regarding this incident. This is attached and has identified the following:”

Source location
Response from Air Balloon Surgery
Page 2 · response
Published 20 September 2022
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
Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.

Verbatim wording from the response
“1. The surgery is fully committed to openness and promoting a learning and improving culture. We have carefully considered the benefits of external scrutiny to help us see beyond any “organisational blind spots” and have appointed an experienced objective external GP and GP Appraiser, who has never worked for the surgery and has knowledge of local systems.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
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
Produce and use a new significant event analysis policy and documentation process for future investigations.

Verbatim wording from the response
“5. Produced a new SEA policy and documentation process. CQC have been given a copy. We feel our new policy and documentation is robust and will result in a better investigation, including risk assessing, analysis, outcome, and written record.”

Source location
Response from Air Balloon Surgery
Page 4 · response
Published 20 September 2022
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
Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.

Verbatim wording from the response
“3. We have reviewed what our regulatory body- CQC- required in terms of investigation and managing incidents. This indicated that the main approach is SEA. GP mythbuster 3: Significant event analysis (SEA) – Care Quality Commission (cqc.org.uk) There is no specific mention of Root Cause Analysis on the website and this is not a technique which is generally used in general practice.”

Source location
Response from Air Balloon Surgery
Page 3 · response
Published 20 September 2022
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to disclose incident investigations and related documents to the Coroner’s office

Inadequate investigation of incidents

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 5

Respondent positions 1