Recipient

Darwin Medical Practice

First report 30 May 2019•Latest report 30 May 2019

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
Published responses: 100%
Concerns addressed: 1
Stated actions: 2

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

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Darwin Medical Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

30 May2019
Stoke-on-Trent and North Staffordshire
Concerns raised2
1. Failure to consider pacemaker box change as a potential source of infection
2. Failure to provide a referral process for patients who become unwell after pacemaker surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review the case and discuss its learning at a clinical governance meeting.
  Stated completed
2. Action
  Consider infection arising from pacemaker leads as a possible cause in future similar presentations.
  Stated planned
Respondent positions 2
1. Position
  The infection could not have been identified earlier within primary care because symptoms were nonspecific and appropriate steps were taken.
  Disputes the concern
1. Position
  Responsibility for the final diagnosis lay probably more within secondary care than primary care.
  Redirects responsibility
AI-generated summary

Geoffrey Duke · 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

Geoffrey Duke became unwell repeatedly after a pacemaker box change in June 2016 and was later found to have infection involving the pacemaker wires. The principal concerns were that the pacemaker was not considered as a possible source of infection, no cardiology referral was made, and there was no evidence of a referral process for patients who became unwell after pacemaker surgery. He died in hospital on 20 December 2017 after deterioration during treatment and surgery.

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 Darwin Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider pacemaker box change as a potential source of infection
Wider context from the report
“Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell. ”
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 Darwin Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide a referral process for patients who become unwell after pacemaker surgery
Wider context from the report
“Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell. ”
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
Review the case and discuss its learning at a clinical governance meeting.

Verbatim wording from the response
“The clinicians at Darwin Medical Practice have met and discussed in depth this case on Thursday 20 June 2019, as part of our regular Clinical Governance Meeting.”

Source location
2019-0256-Response-by-Darwin-Medical-Practice
Page 1 · response
Published 9 September 2019
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
Consider infection arising from pacemaker leads as a possible cause in future similar presentations.

Verbatim wording from the response
“As the GP who was responsible for seeing Mr Duke during most of his visits to the surgery ahead of his death, I have been tasked to write this report, advocated by the coroner at his inquest, given that it was felt there needs to be a structured plan to consider this possibility, should there be any further future instance thereof in any other individual.”

Source location
2019-0256-Response-by-Darwin-Medical-Practice
Page 1 · response
Published 9 September 2019
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
The infection could not have been identified earlier within primary care because symptoms were nonspecific and appropriate steps were taken.

Verbatim wording from the response
“The practice shared the information from HM Coroner and looked back, in detail, through Mr Duke’s medical record. It was agreed that this was an extremely unusual occurrence. It was agreed that the clinicians concerned in Primary Care had made all appropriate steps to try and elucidate. However, during his attendances at the surgery, there could be seen no way that this could have been picked up earlier within Primary Care. Mr Duke had attended on a number of occasions with relatively non-specific symptoms of malaise, with the only finding being of raised inflammatory markers; rightly this had been noted and documented and was being addressed and followed up. In fact, at the last time he was seen at the surgery, he had improved in himself, as indeed had these clinical markers. It was noted that he was concurrently having hospital admissions and attendances.”

Source location
2019-0256-Response-by-Darwin-Medical-Practice
Page 1 · response
Published 9 September 2019
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
Responsibility for the final diagnosis lay probably more within secondary care than primary care.

Verbatim wording from the response
“Given the rareness and the unexpected nature of the eventual outcome, the learning from this in Primary Care was that this is now perceived as a possibility, where it may not have been considered before; the cause for Mr Duke’s malaise. It was felt the remit for the final diagnosis lay probably more within Secondary Care, but that the lesson to be learned from this was that situations, even as unusual as this, are possible and should be considered if any future similar scenario.”

Source location
2019-0256-Response-by-Darwin-Medical-Practice
Page 1 · response
Published 9 September 2019
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to consider pacemaker box change as a potential source of infection

Failure to provide a referral process for patients who become unwell after pacemaker surgery

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.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 2

Respondent positions 2