Church Lane Surgery

Private and voluntary organisations · Multi-service care provider

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First report 20 Oct 2023•Latest report 20 Oct 2023

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
Published responses: 100%
Concerns addressed: 4
Stated actions: 8

Concerns and recipient responses

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

20 Oct2023
Inner North London
Concerns raised4
1. Failure to record relevant family medical history
2. Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department
3. Failure to elicit relevant family medical history
1. Insufficient time in the duty doctor system to deal with patients appropriately
Actions described in response 6
1. Action
  Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
2. Action
  Train staff to collect and accurately record family-history information in the clinical system.
3. Action
  Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
1. Action
  Add three unbooked telephone slots and three face-to-face slots to each duty doctor’s shift.
2. Action
  Audit new family-history entries every 12 months to assess system progress.
3. Action
  Update the NHS health-check template to record negative family history of ischaemic heart disease.
Respondent positions 2
1. Position
  The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
  Disputes the concern
1. Position
  The acute chest symptoms were appropriately investigated and safety-netted regardless of recorded cardiovascular risk factors.
  Disputes the concern
AI-generated summary

Trevor Coy BAILEY · 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

Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.

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 Church Lane Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to record relevant family medical history
Wider context from the report
“1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”
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 Lane Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department
Wider context from the report
“However, it does not appear that these two pieces of information were elicited by those assessing Mr Bailey in the emergency department of Northwick Park Hospital. I heard evidence that, if they had been, he should have been referred to the rapid access chest pain clinic. Given the sequence of events, it seems unlikely that such a referral would have resulted in definitive treatment before Mr Bailey’s fatal myocardial infarction, but it could be a life saving referral for another patient in Mr Bailey’s position. ”
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 Lane Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to elicit relevant family medical history
Wider context from the report
“1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”
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 Lane Surgery; that does not assign responsibility.
PFD Monitor interpretation
Insufficient time in the duty doctor system to deal with patients appropriately
Wider context from the report
“2. ████████ told me in the witness box that she had identified immediately after Mr Bailey’s death in May 2023 that the duty doctor system at Church Lane Surgery does not allow sufficient time to deal with patients appropriately. However, she has not progressed this issue in the five months since. ”
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
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.

Verbatim wording from the response
“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
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
Train staff to collect and accurately record family-history information in the clinical system.

Verbatim wording from the response
“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
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
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.

Verbatim wording from the response
“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
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
Add three unbooked telephone slots and three face-to-face slots to each duty doctor’s shift.

Verbatim wording from the response
“2. Actions to re-structure the On-call system for the Duty doctor.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
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
Audit new family-history entries every 12 months to assess system progress.

Verbatim wording from the response
“Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
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
Update the NHS health-check template to record negative family history of ischaemic heart disease.

Verbatim wording from the response
“We have taken the following steps to update the family history of coronary heart disease (IHD).”

Source location
Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023
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
The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.

Verbatim wording from the response
“It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.”

Source location
Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023
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
The acute chest symptoms were appropriately investigated and safety-netted regardless of recorded cardiovascular risk factors.

Verbatim wording from the response
“On 19.4.23, during his telephone consultation, Mr. Bailey reported a history of chest pain/tightness intermittently for 2 weeks. If a person has a history of chest tightness, it is important to investigate the acute and high risk causes of the symptoms, regardless of whether they have any risk factors for ischaemic heart disease (IHD). This is because there may be a serious underlying cardiac or non-cardiac condition that needs urgent attention, such as pulmonary embolism, cardiac ischemia, aortic dissection or pericarditis,etc. Mr. Bailey was hence advised to go to the emergency department immediately on April 19, 2023.”

Source location
Response from Chuch Lane Surgery
Page 2 · response
Published 6 November 2023
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to record relevant family medical history

Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department

Failure to elicit relevant family medical history

Insufficient time in the duty doctor system to deal with patients appropriately

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.6

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 6

Respondent positions 2