17 Jun 2022 Donald Gore · Prevention of Future Deaths report Avon
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Concerns raised 2 Failure to disclose incident investigations and related documents to the Coroner’s office View source Inadequate investigation of incidents View source
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
Action
Undertake a root cause analysis with detailed risk assessment to identify safety actions.
View source
Action
Review the new significant event analysis system at the practice board meeting after its further use in August.
View source
Action
Complete a second significant event analysis using the revised investigation system.
View source
Action
Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.
View source
Action
Produce and use a new significant event analysis policy and documentation process for future investigations.
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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
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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 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
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 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
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 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
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 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
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 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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations