Alexandra & Crestview Surgeries

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First report 18 Jun 2025•Latest report 18 Jun 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Concerns and recipient responses

Statements from Alexandra & Crestview Surgeries linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Suffolk

    AI-generated summary

    Terence COLBY · 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

    Terence COLBY died on 27 September 2023 after critical limb ischaemia led to a below-knee amputation, followed by hospital-acquired pneumonia and a pulmonary embolism. The principal concern was that his GP practice failed to undertake a simple vascular examination despite a foot wound and leg pain, which was described as substantially sub-standard practice and contrary to national guidelines.

    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 Alexandra & Crestview Surgeries; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake vascular examination of a limb when a foot wound and leg pain are reported

    Wider context from the report

    “During the Course of the Inquest evidence was received in the form of a Report from an Expert in General Practice, commissioned by the Court and which considered the care and treatment provided to Mr. COLBY by his GP Practice (Alexandra & Crestview Surgeries, Lowestoft). The Report highlighted substantially sub-standard practice provided to Mr. COLBY on the 17th August 2023 by Alexandra & Crestview Surgeries. This was as follows: On 17th August 2023, despite the presence of a wound on the foot and the report of leg pain, there was a failure by the examining GP to undertake a simple vascular examination of Mr. COLBY’S limb. The Expert Report highlighted that this was despite the fact that “As per the NICE guidance already quoted, peripheral arterial disease needed to be considered here and this was a patient who had attended face to face. In my view this was substantially sub-standard practice and a failure to provide basic medical care (failure to examine) and was against national guidelines.” Although the Inquest did not conclude that the failure identified above was causative of Mr. COLBY’s death, I am concerned that should such practice continue, without remedial action, then there is a risk of future death in other patients. ”
    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

    Hold a multidisciplinary learning event reviewing peripheral vascular disease, differential diagnosis of foot and lower-limb pain, clinical assessment, red flags and referral criteria.

    Verbatim wording from the response

    “Unfortunately, ████████ is no longer member of staff at this surgery. I understand that she is going to give a response on your invitation to do so. However having reviewed the case of Mr Terence Colby, we feel it would be useful to review the presentation of patients with peripheral vascular disease and consider differential diagnosis of ‘foot and lower limb pain’. We are planning on having a learning event when we will discuss the history, presentation, clinical examination, investigation, and referral criteria particularly when there are red flags which become evident.”

    Source location

    Response from Alexandra & Crestview Surgeries
    Page 2 · response
    Published 3 July 2025

    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

Data last updated 7 September 2026