Recipient

Castlefields Health Centre

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First report 12 Oct 2013•Latest report 12 Oct 2013

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 Castlefields Health Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cheshire

    AI-generated summary

    Carol Ann Gibson · 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

    Carol Ann Gibson, aged 65, died at home on 8 August 2012 following an adverse reaction to nitrofurantoin, which had been prescribed despite an alert in her medical records about a previous adverse reaction. The concerns included failure to heed and appropriately investigate the alert, and possible weaknesses in the practice’s systems and staff understanding for managing patient safety alerts.

    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 Castlefields Health Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a robust system for posting patient safety alerts

    Wider context from the report

    “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”
    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 Castlefields Health Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff understanding and training to respond appropriately to patient safety alerts

    Wider context from the report

    “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”
    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 Castlefields Health Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of posted patient safety alerts to correctly and sufficiently identify the problem

    Wider context from the report

    “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”
    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 Castlefields Health Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check adverse-reaction alerts before prescribing

    Wider context from the report

    “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”
    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