Beccles Medical Centre

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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
5

Described in responses

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.

  1. Suffolk

    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
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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