Covid-19 Pandemic Response Service

Other public bodies · Sub-organisation

Pin Request correction

First report 16 Dec 2020•Latest report 16 Dec 2020

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

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 Covid-19 Pandemic Response Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cumbria

    AI-generated summary

    Patricia Ann Douglas · 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

    Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

    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 Covid-19 Pandemic Response Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on requests for a doctor visit from people feeling very unwell

    Wider context from the report

    “(3) This lady rang for help feeling very unwell, I am told she wanted a doctor to visit, unfortunately nothing happened and it seems very likely that an opportunity to investigate and treat her was missed. I note that two GPs would have been working for the OOH provider at Penrith Hospital –just a mile from Patricia’s home, that Sunday afternoon, one based in the hospital and the other doing home visits. ”
    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 Covid-19 Pandemic Response Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate telephone contact details to support appropriate action after call handling

    Wider context from the report

    “(2) The call was closed by CCAS without further action due to an incorrect telephone number being recorded. The call was from an elderly lady who on the face of it seemed significantly unwell. Would referrals in similar circumstances to local providers [GP or out of hours services] who may be better placed to follow up be worth considering? ”
    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 Covid-19 Pandemic Response Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history

    Wider context from the report

    “(1) The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to the Covid service and does not seem to have given weight to the history of anaemia and transfusion. Could the pathway be improved to give better guidance to call handlers? ”
    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