Recipient

Beccles Medical Centre

First report 18 Jun 2025•Latest report 18 Jun 2025

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
Published responses: 100%
Concerns addressed: 1
Stated actions: 5

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.

100%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

18 Jun2025
Suffolk
Concerns raised1
1. Failure to correctly interpret and apply ReSPECT forms during potentially reversible choking events
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Discuss the analysis findings at the scheduled multidisciplinary meeting and disseminate them to the full practice team.
  Stated planned
2. Action
  Conduct a significant event analysis of the case, focusing on RESPECT form completion, wording, detail and content.
  Stated planned
3. Action
  Arrange relevant additional RESPECT form completion training for the practice team within four weeks.
  Stated planned
1. Action
  Review practice-level clinician training on RESPECT form completion and explore further training needs and delivery options.
  Stated planned
Respondent positions 2
1. Position
  Once the patient became pulseless and entered cardiac arrest, reversibility had ended and the RESPECT form became relevant.
  Disputes the concern
1. Position
  Fundamental changes to RESPECT forms or supporting national guidance should be pursued with the relevant national body.
  Redirects responsibility
AI-generated summary

Kathleen Mary GREGORY · 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

Kathleen Mary GREGORY was found collapsed in bed at her care home on 29 November 2023 after appearing to choke on food, and her death was verified shortly afterwards. A post-mortem examination confirmed asphyxia caused by food lodged in her airway. The concern raised was that a paramedic interpreted the ReSPECT plan as excluding resuscitation during choking, which was considered inconsistent with the form’s terms where the adverse outcome might be reversible.

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 Beccles Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to correctly interpret and apply ReSPECT forms during potentially reversible choking events
Wider context from the report
“During the course of the Inquest the Court heard evidence that the paramedic employed by Beccles Medical Centre who attended Mrs. GREGORY on the 29th November 2023 interpreted a Recommended Summary Care Plan for Emergency Care and Treatment (ReSPECT) in place at the time as meaning that resuscitation attempts should not be attempted in circumstances where an un-natural event such as choking was taking place. I am concerned that such an approach does not appear to be consistent with the terms of a ReSPECT Form and its application in circumstances of an event such as choking where an adverse outcome may be reversable. ”
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
Discuss the analysis findings at the scheduled multidisciplinary meeting and disseminate them to the full practice team.

Verbatim wording from the response
“1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi-Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025.”

Source location
Response from Beccles Medical Centre
Page 2 · response
Published 5 August 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
Conduct a significant event analysis of the case, focusing on RESPECT form completion, wording, detail and content.

Verbatim wording from the response
“1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi-Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025.”

Source location
Response from Beccles Medical Centre
Page 2 · response
Published 5 August 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
Arrange relevant additional RESPECT form completion training for the practice team within four weeks.

Verbatim wording from the response
“2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks.”

Source location
Response from Beccles Medical Centre
Page 2 · response
Published 5 August 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
Review practice-level clinician training on RESPECT form completion and explore further training needs and delivery options.

Verbatim wording from the response
“2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks.”

Source location
Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025
Open published response
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
Once the patient became pulseless and entered cardiac arrest, reversibility had ended and the RESPECT form became relevant.

Verbatim wording from the response
“This case, I would agree, shows a reversible cause at the stage at which the patient was choking and had a pulse (was conscious). As per United Kingdom (UK) resuscitation guidance, one would attempt five back-blows followed by five abdominal thrusts (if the initial intervention was ineffective), in order to try and dislodge the obstruction. At the point at which the patient became pulseless/unresponsive (which as noted in the report was the case when the paramedic was notified of the incident) the patient by definition had gone into cardiac arrest and as per UK resuscitation guidelines one would then commence CPR at this point (ALS/backslaps).”

Source location
Response from Beccles Medical Centre
Page 1 · response
Published 5 August 2025
Open published response
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
Fundamental changes to RESPECT forms or supporting national guidance should be pursued with the relevant national body.

Verbatim wording from the response
“I agree that there is a degree of interpretation with regards to a RESPECT form in such a situation, and that therefore perhaps the wording or structure of the form needs to change. Naturally, this would be an issue for the national issuing body, but if it was felt to be relevant perhaps it is something that could be pursued with them directly.”

Source location
Response from Beccles Medical Centre
Page 1 · response
Published 5 August 2025
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to correctly interpret and apply ReSPECT forms during potentially reversible choking events

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.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 4

Respondent positions 2