Recipient

Audlem Medical Practice

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First report 28 Jun 2018•Latest report 28 Jun 2018

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Robert Maltby Worthington · 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

    John Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

    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 Audlem Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to take or record a full set of observations

    Wider context from the report

    “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem. ”
    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 Audlem Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to investigate persistent back pain and tenderness

    Wider context from the report

    “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem. ”
    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 Audlem Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake further imaging in borderline presentations of significant head injury

    Wider context from the report

    “(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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