Daughter of the deceased

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First report 16 Dec 2013•Latest report 16 Dec 2013

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 Daughter of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Cynthia Fretwell · 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

    Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in consultation and responses to telephone referrals

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to fully and properly document discussions with patients or their families

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to determine an adequate threshold for telephone versus home consultation

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
    Open source report
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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