Recipient

Clacton Community Practices

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First report 16 Jun 2023•Latest report 16 Jun 2023

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
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
3

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.

100%published responses found
3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Essex

    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.

    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 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

    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
    Page 2 · response
    Published 22 June 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

    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
    Page 2 · response
    Published 22 June 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 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
    Page 2 · response
    Published 22 June 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

    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
    Page 1 · response
    Published 22 June 2023

    Open published response
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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

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
67%33%
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