16 Jun 2023 Christine Margaret Cumbers · Prevention of Future Deaths report Essex
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Concerns raised 1 Failure to implement learning from Significant Event Analysis 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. 3
Action
Complete a retrospective audit of consultations to promote clinician reflection and improve patient care.
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Action
Disseminate anonymised learning from the consultation concern at a practice meeting.
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Action
Audit at least one consultation for every clinician annually against recognised criteria and send results for discussion with appraisers.
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AI-generated summary
Christine Margaret Cumbers · 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
Christine Margaret Cumbers was admitted to hospital after developing a skin eruption following treatment with Carbimazole for hyperthyroidism. She developed sepsis during the admission, which was belatedly diagnosed and treated due to a lack of continuity of care caused by multiple ward moves, and this more than minimally contributed to her death. The GP practice also identified shortcomings in earlier care but had not implemented the learning from its review by the date of the inquest.
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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 Clacton Community Practices; that does not assign responsibility.
PFD Monitor interpretation Failure to implement learning from Significant Event Analysis
Wider context from the report “The Practice, despite identifying shortcomings in their practice, took no action to implement the learnings identified in the Significant Event Analysis report and, as at the date of the inquest, no details of plans or timescales for implementation were available .
” 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 Complete a retrospective audit of consultations to promote clinician reflection and improve patient care.
Verbatim wording from the response “As there was no identified systemic failure, the Practice addressed the concern identified in the SEA as described above (with the individual clinician involved) as well as disseminating learning at a practice meeting on 9/8/22 in an anonymous manner, to promote reporting. This said, the Practice also strives to go beyond what is common practice and this is the reason why we decided to audit consultations retrospectively to essentially promote reflection and improve patient care.” Source location Response from Ranworth Medical Group
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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 Disseminate anonymised learning from the consultation concern at a practice meeting.
Verbatim wording from the response “As there was no identified systemic failure, the Practice addressed the concern identified in the SEA as described above (with the individual clinician involved) as well as disseminating learning at a practice meeting on 9/8/22 in an anonymous manner, to promote reporting. This said, the Practice also strives to go beyond what is common practice and this is the reason why we decided to audit consultations retrospectively to essentially promote reflection and improve patient care.” Source location Response from Ranworth Medical Group
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 Audit at least one consultation for every clinician annually against recognised criteria and send results for discussion with appraisers.
Verbatim wording from the response “We can confirm this was completed ahead of schedule on 31/7/23. As detailed in the SEA, it was agreed that every clinician would have at the very least one consultation audited against a known criteria (NHSE audit XL template) once a year and their result sent to them to be discussed with their appraiser. Appraisals are held yearly and are a means to help clinicians reflect on their practice to assure they continue to meet GMC standards. Hence this kind of sporadic monitoring (not mandated anywhere in the country) can never be a valid substitute nor give assurance on overall performance of a given clinician but is rather a quality improving exercise.” Source location Response from Ranworth Medical Group
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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 Risk-assessed signposting and safety-netting by trained non-clinical staff under clinician supervision is considered safe, so no further action is necessary.
Verbatim wording from the response “It is customary for the CCP to contact patients with failed visits within 24 hours. This happened in the case of Mrs Cumbers, as a doctor contacted her on two separate occasions on 25 March 2022. We note that Mrs Cumbers did contact the surgery on 24 March, a few hours after the failed pre-arranged visit. We consider that, whilst it would have been the gold standard for a health care professional (HCP) to be able to speak to Mrs Cumbers directly when she rang to explain why the doctor had failed to gain entry, it was entirely reasonable for Mrs Cumbers to be advised by a non-clinical member of staff at that time, following a clinician’s risk assessment. Such risk assessments are always HCP dependent and include factors such as:
· reason for visit
· living arrangements i.e. does the patient live alone
· past medical history
· carer support etc.” Source location Response from Ranworth Medical Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations