14 Jul 2025 Myles Edward SCRIVEN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Lack of knowledge of requirements for patients with learning disabilities and autism View source Failure to understand and use the Learning Disabilities Register View source Failure to liaise with the Learning Disabilities Service to address missing support arrangements View source Failure to undertake rigorous and detailed internal incident review for learning View source Failure to record numeric observations properly View source Failure to make appropriate adjustments for patients with learning disabilities and autism View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 18
Action
Provide targeted refresher training and administrative escalation training on documenting vital observations and responding promptly to urgent symptoms.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Conduct Practice Protected Time sessions and Significant Event Analyses addressing clinical decision-making, triage, prevention, the case and coroner’s findings.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Implement reasonable adjustments including extended appointments, easy-read correspondence, health passports and proactive recalls for patients with Learning Disabilities and Autism.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Adjust Learning Disability health-check invitations and train staff to manage tailored invitations appropriately.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Use consultation templates, digital prompts, Ardens templates and AI-supported dictation or scribing to improve recording accuracy.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Enhance incident-review policies and processes with clearer documentation, minutes and explicit learning outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Align the Practice Significant Event Policy with the NHS England patient-safety frameworks and disseminate it through Microsoft Teams and hard copy with staff acknowledgements.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Complete Oliver McGowan Level 1 training for all practice staff and schedule Level 2 training for October 2025.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Collaborate with the Strategic Health Facilitator to review the Learning Disability register and improve communication aids, recall processes and patient resources.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Provide mandatory Learning Disability training to new administrative staff and awareness packs to locum doctors.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Train the Practice Manager to discuss reasonable adjustments with patients.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Schedule quarterly Learning from Events meetings to review Significant Event Analyses and share internal and external learning, beginning in January 2026.
Stated plannedThe respondent said that this action was planned when they made their response on 17 July 2025. View source
Action
Hold bimonthly Practice Protected Time meetings incorporating Significant Event Analysis discussions and policy review.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Add Learning Disability and Autism status icons in SystmOne and employ a dedicated coder to maintain accurate records.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Conduct bi-monthly audits of the Learning Disability register, backup plans and hospital passports to verify accuracy and updates.
Stated plannedThe respondent said that this action was planned when they made their response on 17 July 2025. View source
Action
Collaborate with the ICB Data Quality team to verify accurate coding of patients with Learning Disabilities and Autism following migration to SystmOne.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Extend Learning Disability and Autism Health Check appointments from 45 minutes to one hour.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Monitor clinical-observation documentation through audits and peer reviews, including monthly reviews of 20 consultations for three months.
Stated plannedThe respondent said that this action was planned when they made their response on 17 July 2025. View source See 15 more actions
×
AI-generated summary
Myles Edward SCRIVEN · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that he had several contacts with Dalton Surgery while suffering from an ongoing pulmonary embolism, none of which resulted in referral to secondary care, and that the handling of his care contributed to his death. Concerns also included insufficient adjustments and understanding of his autism and learning disabilities, failure to record numeric observations properly, and failure to undertake a rigorous internal review.
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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of requirements for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities . They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and use the Learning Disabilities Register
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the Learning Disabilities Service to address missing support arrangements
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake rigorous and detailed internal incident review for learning
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to record numeric observations properly
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Dalton Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate adjustments for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Provide targeted refresher training and administrative escalation training on documenting vital observations and responding promptly to urgent symptoms.
Verbatim wording from the response “a) Reiterated the importance of thorough documentation of vital clinical observations during consultations, particularly for acute symptoms such as breathlessness, through targeted clinical safety refresher training where needed.”
Source location Response from Dalton Surgery Page 3 · response Published 17 July 2025
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 Conduct Practice Protected Time sessions and Significant Event Analyses addressing clinical decision-making, triage, prevention, the case and coroner’s findings.
Verbatim wording from the response “a) Conducted two Practice Protected Time (PPT) sessions in June and October 2025 focusing on clinical decision-making, triage, and prevention.”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Implement reasonable adjustments including extended appointments, easy-read correspondence, health passports and proactive recalls for patients with Learning Disabilities and Autism.
Verbatim wording from the response “d) Implemented standard reasonable adjustments for patients, including extended appointment times, easy-read correspondence, health passports, and proactive recall systems.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Adjust Learning Disability health-check invitations and train staff to manage tailored invitations appropriately.
Verbatim wording from the response “k) Adjusted invitation scheduling for LD health checks to ensure all patients are invited appropriately, with staff trained on tailored invitation management.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Use consultation templates, digital prompts, Ardens templates and AI-supported dictation or scribing to improve recording accuracy.
Verbatim wording from the response ““I acknowledge that my consultation record was poor and lacking in important details – particularly quantitative values for examination findings. This is not usual for my way of working. I am confident that such observations were in fact undertaken and were satisfactory, but unfortunately, they were not recorded. In light of this, I have changed my practice: I now use internal systems and templates to prompt and facilitate proper capture of these values in every consultation.””
Source location Response from Dalton Surgery Page 3 · response Published 17 July 2025
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 Enhance incident-review policies and processes with clearer documentation, minutes and explicit learning outcomes.
Verbatim wording from the response “d) Enhanced policies and processes for incident reviews now include clearer documentation, minutes, and explicit learning outcomes.”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Align the Practice Significant Event Policy with the NHS England patient-safety frameworks and disseminate it through Microsoft Teams and hard copy with staff acknowledgements.
Verbatim wording from the response “f) Updated the Practice Significant Event Policy, accessible on Microsoft Teams and in hard copy with signed staff acknowledgements, is being aligned with the NHS England Patient Safety Incident Response Framework (PSIRF) and the Primary Care Patient Safety Strategy for GP practices.”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Complete Oliver McGowan Level 1 training for all practice staff and schedule Level 2 training for October 2025.
Verbatim wording from the response “b) All practice staff have completed Oliver McGowan Level 1 training, with Level 2 training scheduled for October 15th and 28th 2025.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Collaborate with the Strategic Health Facilitator to review the Learning Disability register and improve communication aids, recall processes and patient resources.
Verbatim wording from the response “f) Engaged with Jessica Atkinson (Strategic Health Facilitator for Kirklees Adult Learning Disability) to jointly review the LD register and enhance communication aids, recall processes, and patient resources. A follow-up visit is planned for October 2025.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Provide mandatory Learning Disability training to new administrative staff and awareness packs to locum doctors.
Verbatim wording from the response “c) New administrative staff receive mandatory LD training before commencing duties; locum doctors are provided with LD awareness packs.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Train the Practice Manager to discuss reasonable adjustments with patients.
Verbatim wording from the response “e) Practice Manager received bespoke training on discussing reasonable adjustments with patients.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Schedule quarterly Learning from Events meetings to review Significant Event Analyses and share internal and external learning, beginning in January 2026.
Verbatim wording from the response “Going forward, the Practice will schedule quarterly Learning from Events meetings to review SEAs and share learning from both internal and external cases to promote shared learning. The first quarterly meeting is scheduled for January 2026. This will be in line with the Primary care patient safety strategy and Learning from Patient Safety Events (LFPSE).”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Hold bimonthly Practice Protected Time meetings incorporating Significant Event Analysis discussions and policy review.
Verbatim wording from the response “g) Bimonthly PPT meetings regularly incorporate SEA discussions and policy review to reinforce staff understanding.”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Add Learning Disability and Autism status icons in SystmOne and employ a dedicated coder to maintain accurate records.
Verbatim wording from the response “i) Added patient icons in SystmOne to flag LD and Autism status; employed a dedicated coder to maintain accurate records.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Conduct bi-monthly audits of the Learning Disability register, backup plans and hospital passports to verify accuracy and updates.
Verbatim wording from the response “The Practice plans to undertake bi-monthly audits of all patients on the LD Register to confirm its accuracy and updated back-up plans and hospital passports where necessary. The purpose of the audit is to affirm that the LD Register is being used with 100% accuracy and regular audits will continue to be carried out. Please refer to the attached action plan for audit details and scheduling.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Collaborate with the ICB Data Quality team to verify accurate coding of patients with Learning Disabilities and Autism following migration to SystmOne.
Verbatim wording from the response “c) Following migration to SystmOne, collaborated with the ICB Data Quality team to verify and ensure accurate coding of patients with LD and Autism.”
Source location Response from Dalton Surgery Page 4 · response Published 17 July 2025
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 Extend Learning Disability and Autism Health Check appointments from 45 minutes to one hour.
Verbatim wording from the response “g) Extended appointment length for LD and Autism Health Checks from 45 minutes to one hour.”
Source location Response from Dalton Surgery Page 2 · response Published 17 July 2025
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 Monitor clinical-observation documentation through audits and peer reviews, including monthly reviews of 20 consultations for three months.
Verbatim wording from the response “c) Reminded clinical staff of documentation’s role in decision-making and safety-netting; compliance monitored via audits and peer reviews, detailed in the enclosed action plan.”
Source location Response from Dalton Surgery Page 3 · response Published 17 July 2025
Open published response