8 Jul 2024 Michael HUGGON · Prevention of Future Deaths report Cumbria
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Concerns raised 3 Delays in dealing with urgent requests View source Failure to provide a rapid and secure handover of unfinished work when practice workload cannot be managed View source Referral to 111 causing delays and undue pressure on the service View source
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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.
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× 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
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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
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations