Churchgate Surgery

Health and care · Healthcare site

Pin Request correction

First report 19 Jan 2016•Latest report 16 Feb 2017

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
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Manchester South

    AI-generated summary

    Thomas Josef Green · 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

    Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD services.

    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider and action referrals to Adult General Psychiatry

    Wider context from the report

    “1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned. ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of commissioned services for complex PTSD and complex presentations

    Wider context from the report

    “5. The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green. ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient detail in GP referral documentation to identify case complexity

    Wider context from the report

    “4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted. ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of treatment plans addressing complex PTSD

    Wider context from the report

    “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Inappropriate referral of complex PTSD presentations to Healthy Minds

    Wider context from the report

    “3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD. ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of psychiatric follow-up after hospital discharge

    Wider context from the report

    “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. ”
    Open source report

  2. Manchester South

    AI-generated summary

    Irene Anne Pearson · 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

    Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to define the terms “prolonged” and “hot” in the hot-bath warning

    Wider context from the report

    “2. Even when the said warning phrase is reached in the leaflet, it then refers to “a prolonged hot bath” without in any way defining the words “prolonged” or “hot”. These terms are easily open to subjective interpretation, which may lead to an unsafe usage environment. (Takeda UK) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reconcile prescribed opiate patches with the patient’s actual possession

    Wider context from the report

    “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain clear and sufficiently detailed electronic clinical notes

    Wider context from the report

    “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a full report of the patient’s care

    Wider context from the report

    “6. When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient’s records. (Churchgate Surgery) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches

    Wider context from the report

    “3. I heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the ‘exhausted’ patch so as to aid removal. The toxicologist point out that even when due for changing the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore be inherently potentially dangerous.(Macmillan Cancer Care) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch

    Wider context from the report

    “1. The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4th bullet point) that there is reference to the danger of taking a hot bath whilst wearing the patch. The Forensic Consultant Toxicologist gave evidence to me that heating of the body will cause an onrush of the delivery of the drug. (Takeda UK) ”
    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 Churchgate Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of liaison with the GP Practice over regulation of additional opiate pain-control

    Wider context from the report

    “4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this.(Macmillan Cancer Care) ”
    Open source report
Back to top

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