Concerns raised 6 Lack of clear responsibility for care of patients during illness View source Failure to notify NWAS when referred emergency calls remain unresolved View source Overcomplexity of the care system obscuring urgent care needs View source Insufficient overnight capacity to triage waiting calls View source Failure to alert call handlers to recent same-condition contacts View source Failure to alert control when transferred emergency cases remain unresolved View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas Raymond Mallinson · 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 Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to notify NWAS when referred emergency calls remain unresolved
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them . As referred to above -where does responsibility lie?
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Overcomplexity of the care system obscuring urgent care needs
Wider context from the report “(4) To ████████, Secretary of State for Health.
In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself, and I remarked that I felt Thomas "had fallen through an overcomplex system and was indeed neglected". I am aware that you are hoping to develop a 10 year plan for the NHS and therefore feel it my duty to highlight this case to you as an example of how overcomplexity has lost sight of a man's urgent care needs .
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight capacity to triage waiting calls
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload . I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above -where does responsibility lie?
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to alert call handlers to recent same-condition contacts
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to alert control when transferred emergency cases remain unresolved
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with . A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 Continue discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
Verbatim wording from the response “2. The ICB have been informed of the receipt of the Regulation 28. I have had meetings with their quality team looking at how we manage the “shoulder time” at the daytime practice/Out of Hours interface. These discussions are ongoing as currently there is no formal agreement on how cases are managed and I have raised the possibility with the ICB about an MOU with all practices that would” Source location Response from Cumbria Health
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 Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Verbatim wording from the response “In terms of the updated policy, we have put in place a clear process for managing calls that we cannot deal with overnight to reduce the risk of simply handing them all back to the daytime GP practices (page 13 in Clinical Operational Policy). We now provide a welfare call to patients in the overnight period in whom we have breached their response times. If there are concerns of deterioration then the case is escalated to a Clinician as priority. As discussed at inquest we will be adopting an automated text system to do the welfare checks with Adastra (our patient record software provider) when it becomes available which we understand will be by the end of the year.” Source location Response from Cumbria Health
Open published response
8 Jul 2024 Michael HUGGON · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Delays in dealing with urgent requests View source Failure to provide a rapid and secure handover of unfinished work when practice workload cannot be managed View source Referral to 111 causing delays and undue pressure on the service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael HUGGON · 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
Michael Huggon, who had declining health and profound anaemia, became seriously unwell on 6 February 2024. After delays in obtaining urgent medical assistance and a hospital admission was declined, he collapsed in cardiac arrest shortly after midnight and died in hospital on 7 February 2024. The principal concerns were delays and an inadequate handover in responding to the urgent request for help, with concern that earlier assessment and admission might have enabled a blood transfusion and prevented his death.
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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in dealing with urgent requests
Wider context from the report “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources. The response from Carlisle Healthcare to a request for urgent help was in my view inadequate , however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died.
(2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly , and that if a practice can not deal with its workload a rapid and secure handover process is put in place. I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service.
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a rapid and secure handover of unfinished work when practice workload cannot be managed
Wider context from the report “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources. The response from Carlisle Healthcare to a request for urgent help was in my view inadequate, however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died.
(2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly, and that if a practice can not deal with its workload a rapid and secure handover process is put in place . I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service.
” 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 Cumbria Health Limited; that does not assign responsibility.
PFD Monitor interpretation Referral to 111 causing delays and undue pressure on the service
Wider context from the report “(1) I was told at the hearing that it is now normal practice for any work unfinished by surgery closing time is left to the after hours service and that GPs no longer "call in on the way home". In this case there was no handover and the Huggons had to start their patient journey all over again -with a long delay to even speak to 111. The process was slow and inefficient with multiple doctors on call handlers involved [by my calculation 4 call handlers/receptionists, 1 nurse and 3 doctors]. I was previously aware that many ambulance calls promised by 111 are sent to Cumbria Health for re-triage to try to prioritize resources . The response from Carlisle Healthcare to a request for urgent help was in my view inadequate, however when Cumbria Health were eventually involved their response was timely. I suspect Michael was exhausted and almost beyond caring when he declined admission in the evening, but feel it is most likely that had he been seen and admitted to hospital earlier he could have received a blood transfusion and would not have died.
(2) Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly, and that if a practice can not deal with its workload a rapid and secure handover process is put in place. I am also concerned that referral to 111 will continue to bring delays and place undue pressure on that service .
” 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 Disseminate guidance to all GP practices on options for discussing and handing over cases of concern, including standalone communication and website publication.
Verbatim wording from the response “• We will ensure that the information in the section above is communicated to the GP practices through all of Cumbria on the options Cumbria Health has for discussing and handing over cases of concern if they are unable to manage them within the constraints of their capacity, particularly at that shoulder time period of when they close and the Cumbria Health opens. This will be achieved by a standalone communication and guidance will be entered onto our newly developed website for ease of access.” Source location Response from Cumbria Health
Open published response
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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 Existing information-sharing and clinical handover processes are considered sufficient to mitigate communication risks between healthcare organisations.
Verbatim wording from the response “Cumbria Health has for many years had processes in place to allow the exchange of clinical information between organisations that include not only daytime primary care but other organisations such as community nurses, hospice, and secondary care. We are very aware that communication issues are often the cause of situations where things could have gone better for patients and the measures, we already have in place are there to mitigate this risk. We also fully recognise the pressures on daytime practice which include capacity to address all the patient queries that arrive at the practice before the 18.30pm handover to Cumbria Health.” Source location Response from Cumbria Health
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations