4 Jan 2021 Pardeep Singh PLAHE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login View source Failure of EMIS consultation lists to update reliably View source Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error View source
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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.
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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 Ashfield Surgery; that does not assign responsibility.
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.
” 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 Ashfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of EMIS consultation lists to update reliably
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.
” 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 Ashfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error
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.
” 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 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
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 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
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 Check that the relevant computer ports are open to address the EMIS appointment-screen refresh problem.
Verbatim wording from the response “Second issue was the problem with EMIS and not refreshing the appointments.
█ had highlighted this on 30.7.2020. Even manually refreshing the screen didn’t highlight new patients added and literally had to log on and odd the system and only then did patients appear. There have been other bugs with the IT system.
█ pointed out these were escalated to EMIS on 4/8/20 by █.
They suggested to check computer ports were open.” Source location 2021-0061-Response-from-Ashfield-Surgery-Redacted
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 Chase the IT desk and further escalate the EMIS appointment-screen refresh problem.
Verbatim wording from the response “Second issue was the problem with EMIS and not refreshing the appointments.
█ had highlighted this on 30.7.2020. Even manually refreshing the screen didn’t highlight new patients added and literally had to log on and odd the system and only then did patients appear. There have been other bugs with the IT system.
█ pointed out these were escalated to EMIS on 4/8/20 by █.
They suggested to check computer ports were open.” Source location 2021-0061-Response-from-Ashfield-Surgery-Redacted
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 EMIS is expected to provide the system solution for appointment screens not refreshing; the practice has not received one.
Verbatim wording from the response “Please find enclosed a Significant Event Analysis that was done shortly after the event. The altered induction pack was updated IN January 2021. We have yet to receive a solution from EMIS.” Source location 2021-0061-Response-from-Ashfield-Surgery-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations