Attleborough Surgery

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First report 26 Mar 2025•Latest report 26 Mar 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
7

Described in responses

Concerns and recipient responses

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

  1. Norfolk

    AI-generated summary

    Derek William COLE · 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

    Derek Cole, who had metastatic prostate cancer, was found unresponsive at Dereham Hospital in the early hours of 16 June 2024 and was not resuscitated in accordance with his previously expressed wishes. The principal concerns were that an abnormally high PSA result was not promptly flagged to the Urology team and that the GP practice had not held a review or implemented learning nine months after his death, creating a risk of similar future events.

    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 Attleborough Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct timely review and learning from patient-safety concerns

    Wider context from the report

    “1. It was accepted that the GP practice, when asked to perform tests by secondary services, should notify them of the results if they are abnormal. It was accepted that it should be confirmed in such circumstances that a follow up appointment is in place and considered whether any abnormal results should lead to a request for a more urgent review. It was also accepted that there was learning for the practice regarding this and that this could be discussed at a Significant Event meeting. However, despite Mr Cole dying in June 2024, at the time of inquest, 9 months later no such meeting or learning had taken place. While the evidence is that earlier specialist input would not have altered the outcome for Mr Cole, it is a concern that for other patients, a delay may impact upon their treatment options and prognosis. 2. The evidence was that any clinician could identify a concern for these meetings, or that usually it was for the Practice Manager to raise these when they were aware of a concern. The Practice were aware of the concerns as the inquest was listed and concerns raised by the family about delays were sent to the Practice to consider when providing their evidence for the inquest. However, this still did not trigger a review or any learning. It is therefore a concern that the Practice does not have a sufficient system in place to learn from such events which creates a risk that future deaths may occur in similar circumstances. ”
    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

    Deliver training for GPs and all staff on the amended SEA and reporting protocols.

    Verbatim wording from the response

    “Training for GPs and all staff is planned for 04.06.25 to cover the new protocols, which have already been circulated.”

    Source location

    Response from Attleborough Surgery
    Page 3 · response
    Published 27 March 2025

    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

    Audit deaths over three months to assess appropriate SEA referrals under the amended protocol and present the findings at a clinical meeting.

    Verbatim wording from the response

    “The surgery plans an audit of all deaths over the next 3 months to measure how many are being referred appropriately for a SEA, according to the amended protocol. The audit will then be presented for discussion at a clinical meeting at the practice.”

    Source location

    Response from Attleborough Surgery
    Page 3 · response
    Published 27 March 2025

    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

    Amend and circulate SEA and death-reporting protocols to include delays in care, relevant near misses and low-threshold staff reporting and case discussion.

    Verbatim wording from the response

    “As a result, the SEA protocol has been amended and circulated to all clinicians. There is clarification that it is the responsibility of the clinician involved in the patient’s care to report to the Practice Manager and Practice PA, but any staff member who identifies a concern should also have a low threshold for reporting to them as well. Similarly, any staff member with a concern that a significant/critical event could have taken place should have a low threshold for discussing the case with a colleague.”

    Source location

    Response from Attleborough Surgery
    Page 3 · response
    Published 27 March 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