11 Mar 2024 Keith Smith · Prevention of Future Deaths report East London
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Concerns raised 3 Failure to demonstrate improvement in recording of patient calls View source Failure to demonstrate improvement in monitoring of GP call-backs to patients View source Failure to demonstrate improvement in escalation of patient enquiries to GPs View source
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. 9
Action
Review and update communication, escalation and emergency policies through team engagement and a review process.
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Action
Provide staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.
View source
Action
Develop and use a Message Book protocol and telephone call supervision audit.
View source
Action
Implement regular communication audits, call listening, patient-feedback reviews and training-adherence evaluations.
View source
Action
Deliver scenario-based triage training and schedule recurring biannual sessions, with additional training when needed.
View source
Action
Establish a comprehensive staff training programme, including provider engagement, identified learning needs and arrangements to release staff for training.
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Action
Provide Lead GP reception support for staff queries, message-book use and care navigation during busy periods.
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Action
Stop using screen messaging for patient or clinical matters and use the tracked message book or direct clinician communication instead.
View source
Action
Develop a reliable auditable communication system by using EMIS messaging, retaining tracked message-book processes and building an urgent-communication template.
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AI-generated summary
Keith Smith · 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
Keith Smith experienced worsening back and chest pain in early July 2023 and sought help from his GP on 3, 4 and 5 July. GP call-backs did not occur, and on 5 July his family contacted 111, after which an ambulance diagnosed a myocardial infarction; he suffered cardiac arrest and died shortly after midnight on 6 July 2023. The principal concern was that the GP surgery could not provide persuasive evidence that procedures, staffing and training had improved the recording and escalation of calls or the monitoring of GP call-backs.
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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 Church Elm Lane Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate improvement in recording of patient calls
Wider context from the report “The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls , the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients.
” 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 Church Elm Lane Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate improvement in monitoring of GP call-backs to patients
Wider context from the report “The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients.
” 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 Church Elm Lane Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate improvement in escalation of patient enquiries to GPs
Wider context from the report “The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients.
” 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 Review and update communication, escalation and emergency policies through team engagement and a review process.
Verbatim wording from the response “Policy and Procedure Review” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Provide staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.
Verbatim wording from the response “Staff Training on Message Escalation: Training sessions were conducted to emphasize the importance of using the auditable message book for call escalation with direct communication with doctors for urgent concerns and screen messages not to be used for any patient-related queries. Two targeted internal training events with clinical and non-clinical staff have taken place to review and implement changes to the process of escalating clinical matters to the clinical team, and following up on this to see if this has been addressed and actioned (Appendix 1, 2, 3).” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Develop and use a Message Book protocol and telephone call supervision audit.
Verbatim wording from the response “Following regular meetings with staff we have developed a Message Book protocol (Appendix 9) and a call supervision audit (Appendix 7)” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 regular communication audits, call listening, patient-feedback reviews and training-adherence evaluations.
Verbatim wording from the response “Objective: Implement a monitoring and evaluation framework to regularly assess the effectiveness of communication practices and protocols.” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Deliver scenario-based triage training and schedule recurring biannual sessions, with additional training when needed.
Verbatim wording from the response “Listening to staff calls on a regular basis and assessing training needs. Following the Coroner's report, we audited a random selection of telephone calls and gave 1:1 feedback (Appendix 7). Scenario-based training on triage protocols to ensure staff are prepared to escalate calls appropriately was undertaken at our training session on 22/4/24, where all non-clinical staff were present. These sessions will be run on a biannual basis (Appendix 4). However, if we need to complete any ad hoc training – based on need, we will. We are also exploring other training offers on this by the ICS and ICB such as training on care navigation and pharmacy first. On Monday mornings which is our busiest times there is a GP at reception to observe and help with queries and navigations.” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Establish a comprehensive staff training programme, including provider engagement, identified learning needs and arrangements to release staff for training.
Verbatim wording from the response “Comprehensive Staff Training Program” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Provide Lead GP reception support for staff queries, message-book use and care navigation during busy periods.
Verbatim wording from the response “GP Observation of Reception Staff: To gain an immediate insight of the current situation, a Lead GP has spent time at reception to help staff with queries and to deal with any concerns regarding the message book. With the Lead GP present, staff have been able to ask questions immediately, provide and receive feedback, and gain confidence in the new procedure. To ensure understanding and compliance with training, we are looking at mechanisms to embed systems and processes for regular review and reporting of monitoring and training.” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Stop using screen messaging for patient or clinical matters and use the tracked message book or direct clinician communication instead.
Verbatim wording from the response “Care Navigation and Escalation Training: Staff were instructed to immediately stop using the screen messaging system for patient or any clinical related matters or communication, favouring the message book and/or direct doctor communication. All staff encouraged to seek help and advice if they were concerned about any patient contact. We are currently in discussions with the ICB (Integrated Care Board) and CEPN (Community Education Provider Network) on how we can access this training on a regular basis, not just for our staff but all staff across Barking and Dagenham.” Source location Response from Church Elm Lane Medical Practice
Open published response
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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 Develop a reliable auditable communication system by using EMIS messaging, retaining tracked message-book processes and building an urgent-communication template.
Verbatim wording from the response “Objective: Implement a robust, failsafe communication system that ensures all patient calls and messages are logged, tracked, and audited effectively.” Source location Response from Church Elm Lane Medical Practice
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