Carlisle Healthcare

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First report 8 Jul 2024•Latest report 8 Jul 2024

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
3

Across all linked responses

Stated actions
3

Described in responses

Concerns and recipient responses

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

  1. Cumbria

    AI-generated summary

    Michael HUGGON · 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

    Michael Huggon, who had declining health and profound anaemia, became seriously unwell on 6 February 2024. After delays in obtaining urgent medical assistance and a hospital admission was declined, he collapsed in cardiac arrest shortly after midnight and died in hospital on 7 February 2024. The principal concerns were delays and an inadequate handover in responding to the urgent request for help, with concern that earlier assessment and admission might have enabled a blood transfusion and prevented his death.

    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 Carlisle Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in dealing with urgent requests

    Wider context from the report

    “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources. The response from Carlisle Healthcare to a request for urgent help was in my view inadequate, however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died. (2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly, and that if a practice can not deal with its workload a rapid and secure handover process is put in place. I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service. ”
    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 Carlisle Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a rapid and secure handover of unfinished work when practice workload cannot be managed

    Wider context from the report

    “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources. The response from Carlisle Healthcare to a request for urgent help was in my view inadequate, however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died. (2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly, and that if a practice can not deal with its workload a rapid and secure handover process is put in place. I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service. ”
    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 Carlisle Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Referral to 111 causing delays and undue pressure on the service

    Wider context from the report

    “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources. The response from Carlisle Healthcare to a request for urgent help was in my view inadequate, however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died. (2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly, and that if a practice can not deal with its workload a rapid and secure handover process is put in place. I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service. ”
    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

    Implement Modern General Practice Access, including structured demand assessment, central care navigation and GP review of clinical requests.

    Verbatim wording from the response

    “Carlisle Healthcare implemented “Modern General Practice Access” in June 2023. This aimed to improve patient experience of contacting the surgery, see and understand all expressed patient demand (removing the need to “call back tomorrow”), and respond to that need (to offer the right care with the most appropriate clinician or service in a safe time frame).”

    Source location

    Response from Carlisle Healthcare
    Page 2 · response
    Published 30 July 2024

    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

    Pass triaged cases requiring same-day clinical input after closure directly to Cumbria Health by telephone.

    Verbatim wording from the response

    “Following discussion with Cumbria Health, we have agreed that any cases that have already been triaged and need same day clinical input after we have closed will be passed directly to Cumbria Health via telephone, instead of asking the patient to contact 111. This should improve the patient experience of care and reduce delay in response times.”

    Source location

    Response from Carlisle Healthcare
    Page 4 · response
    Published 30 July 2024

    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

    Implement a performance indicator requiring clinician triage of all acute home-visit requests within 60 minutes.

    Verbatim wording from the response

    “Following internal discussion within Carlisle Healthcare we have agreed to implement a performance indicator that all requests for acute home visits will be triaged by a clinician within 60 minutes.”

    Source location

    Response from Carlisle Healthcare
    Page 4 · response
    Published 30 July 2024

    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