19 Aug 2025 Venetia Clarissa Pierce · Prevention of Future Deaths report Surrey
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Concerns raised 3 Failure of nitrofurantoin safety alert criteria to cover patients without pre-existing pulmonary disease View source Failure of the surgery EMIS system to display MHRA nitrofurantoin safety alerts View source Limited clinician awareness of nitrofurantoin pulmonary damage and respiratory failure in elderly patients View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Venetia Clarissa Pierce · 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
Venetia Clarissa Pierce, described as an elderly frail lady with recurrent urinary infections, was prescribed nitrofurantoin prophylactically in February 2024 and died in hospital on 30 December 2024. The inquest recorded nitrofurantoin-induced pneumonitis as the medical cause of death, with frailty contributing. Concerns included the absence of an MHRA safety alert on the surgery’s EMIS system and limited awareness among clinicians of the potential for pulmonary damage and respiratory failure from nitrofurantoin in elderly patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of nitrofurantoin safety alert criteria to cover patients without pre-existing pulmonary disease
Wider context from the report “a. The MHRA issued a drug safety alert regarding the risks of pulmonary and hepatic adverse drug reactions in relation to nitrofurantoin in April 2023. However, no MHRA safety alert appeared on the surgery EMIS system when the drug was prescribed to Mrs Pierce. The court heard that the safety alert only arises when patients have a pre-existing pulmonary disease which Mrs Pierce did not have .
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the surgery EMIS system to display MHRA nitrofurantoin safety alerts
Wider context from the report “a. The MHRA issued a drug safety alert regarding the risks of pulmonary and hepatic adverse drug reactions in relation to nitrofurantoin in April 2023. However, no MHRA safety alert appeared on the surgery EMIS system when the drug was prescribed to Mrs Pierce . The court heard that the safety alert only arises when patients have a pre-existing pulmonary disease which Mrs Pierce did not have.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Limited clinician awareness of nitrofurantoin pulmonary damage and respiratory failure in elderly patients
Wider context from the report “b. Although a “recognised” complication, understanding of the potential for pulmonary damage and respiratory failure from use of nitrofurantoin in the elderly may remain low . The court heard evidence from a respiratory consultant that awareness amongst GPs, hospital clinicians including urologists was limited and that even if Mrs Pierce had been referred to hospital earlier the condition might not have been diagnosed.
” Open source report
18 Apr 2024 ALEXANDER LEE REID · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
ALEXANDER LEE REID · 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
Alexander Lee Reid received the Oxford AstraZeneca Covid-19 vaccine after being invited early because an erroneous BMI in his GP records led him to be identified as vulnerable. He died on 29 June 2021, and the inquest concluded that his death was linked to the vaccination, with the medical cause recorded as cerebral venous sinus thrombosis and Covid-19 vaccine-induced immune thrombotic thrombocytopenia. The principal concern was whether general practice IT systems should validate or challenge potentially erroneous data at the point of entry to improve data reliability and patient safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry
Wider context from the report “(2) The inquest heard expert evidence that the combined vaccination monitoring and recall specification designed to identify vulnerable people for the purposes of inviting them to receive their Covid vaccinations early had identified Alex as vulnerable from an incorrect BMI of 68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician recording Alex's height as 145cm and his weight as 145kg, giving a BMI of 68.97 for an 11 year old boy whose previously recorded BMI aged 9 had been 14.88.
(3) The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual's GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme.
(4) The inquest heard expert evidence that an easier and more appropriate option would be to embed validation rules in general practice IT systems that would check such information at the time of data entry .
(5) If the obviously erroneous BMI had not been recorded or had been challenged at the point of entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have been offered a vaccine before guidance was published that the under 30’s should not receive the Oxford Astra Zeneca vaccine, and would not have died when he did.
(6) The consequences of the data input error in this case give rise to a concern that more might be done by way of specification design to allow for the correction of or challenge to potential data input errors at the point of entry , with consequential improvements in the reliability of such data and the safety of patients and reducing the risk of other deaths occurring in similar circumstances in the future.
” Open source report
22 Mar 2024 Finlay Stuart Ian FINLAYSON · Prevention of Future Deaths report East Sussex
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Concerns raised 2 Failure to reliably transfer key medical information between incompatible systems View source Delays in transferring medical information to prison healthcare staff View source
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AI-generated summary
Finlay Stuart Ian FINLAYSON · 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
Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably transfer key medical information between incompatible systems
Wider context from the report “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison.
Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems.
I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand .
I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other . I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring medical information to prison healthcare staff
Wider context from the report “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison.
Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems.
I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand.
I am concerned about the potential delay this process could cause . I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient.
” 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 Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.
Verbatim wording from the response “We have undertaken an internal review of EMIS Web, focussing on the issues raised as areas of concern in the Report in relation to EMIS Web, namely a potential lack of interaction between clinical systems in prisons (predominantly SystmOne) and other clinical systems in community GP surgeries, and the evidence you heard that notes have to be printed and scanned on to SystmOne, with key information inputted manually, if an individual’s GP practice uses a clinical system other than SystmOne.” Source location Response from EMIS
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 Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.
Verbatim wording from the response “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.” Source location Response from EMIS
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 Continue reviewing EMIS solutions to identify potential performance improvements affecting medical-record transfers.
Verbatim wording from the response “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.” Source location Response from EMIS
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 GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.
Verbatim wording from the response “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.” Source location Response from EMIS
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 EMIS cannot control whether prisons request medical records through GP2GP or a manual process.
Verbatim wording from the response “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.” Source location Response from EMIS
Open published response
26 Jun 2023 Matthew William Thomas Power · Prevention of Future Deaths report Surrey
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Concerns raised 3 Failure of EMIS prescription records to clearly display the chronology of issued prescriptions View source Failure of ended repeat prescriptions to be removed from pending medication-management queues View source Difficulty interrogating EMIS prescribing records to establish what was prescribed, issued and when View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Matthew William Thomas Power · 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
Matthew William Thomas Power, a 33-year-old man living in supported accommodation, died at a house in Redhill after taking illicit and prescribed drugs over the previous 36 hours; the medical cause of death was recorded as mixed drug toxicity. The concerns identified related to the EMIS prescribing system, including cancelled prescriptions remaining pending, prescriptions being grouped in a way that obscured prescribing history, and difficulty determining what had been prescribed and issued.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of EMIS prescription records to clearly display the chronology of issued prescriptions
Wider context from the report “2. I heard evidence that the EMIS system appears to group prescriptions into the amount prescribed rather than simply recording when a prescription is issued . In this case there were different entries grouped as 100 tablets, 50 tablets, 30 tablets, and 24 tablets. Consequently, it was not clear to the duty doctor that the most recent prescriptions for co-codamol had been for a shorter course of only █ tablets and as a result █ tablets of co-codamol were prescribed and issued.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of ended repeat prescriptions to be removed from pending medication-management queues
Wider context from the report “1. The GP practice uses EMIS for patient records and prescribing. From the evidence it appears that when one doctor ends a repeat prescription on EMIS, it remains in the 'pending' Medication Management box of the doctor to whom it was originally sent . Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled .
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Difficulty interrogating EMIS prescribing records to establish what was prescribed, issued and when
Wider context from the report “3. Evidence was given by the GP practice that to interrogate the EMIS system in order to ascertain what had actually been prescribed, issued and when, was a challenging task ; it had taken 3 GPs and the in-house pharmacist to conduct the review .
” Open source report
Concerns raised 1 Lack of automatic GP-record alerts for smear-test non-responders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Rachelle Naomi Ross · 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
Rachelle Naomi Ross, aged 34, had not undergone a smear test before being diagnosed with squamous cell carcinoma in November 2020. Despite treatment, the cancer metastasised and she died at home on 20 April 2022. The report raised concerns that GP systems did not automatically flag patients who failed to attend smear tests, potentially requiring manual recording of warnings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic GP-record alerts for smear-test non-responders
Wider context from the report “1. During the course of the inquest I heard evidence from ████████, GP Partner at the Collingwood Health Group who informed me that GP practice records do not include an alert from EMIS or System 1 IT systems to provide an automatic flag on a patient's GP medical records if they are classed as a non-responder for a smear test by the National Screening Service.
2. The alert system is only triggered after a patient attends a smear test. For a non-responder, they go back into the three or five year waiting list for a National Screening invitation for a smear test.
3. An automatic flag or alert when a patient fails to attend for a smear test as part of the National Screening Service, would mean that a GP surgery would not have to manually add a warning as an entry onto an individual’s GP records. It would standardise the approach across all GP surgeries and could increase patient safety.
” Open source report
1 Feb 2023 Hugo Carlos · Prevention of Future Deaths report Berkshire
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Concerns raised 1 Failure of the practice follow-up system to ensure investigations are completed at the correct time View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Hugo Carlos · 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
Hugo Carlos died in November 2021 after developing obstructive jaundice caused by a liver lesion and undergoing procedures including biliary drain insertion and hepatic artery embolization. The principal concern was that the EMIS system did not reliably alert general practitioners when follow-up investigations were due, placing responsibility on patients and creating a continuing risk that patients could be lost to necessary follow-up.
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× 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the practice follow-up system to ensure investigations are completed at the correct time
Wider context from the report “A partner in the Deceased’s general practice gave evidence to the Inquest that the practice uses the EMIS system, and that, unlike SystemOne, the system does not have a scheduled task feature which would allow the GP to create an alert on a patient’s record to flag up when a task is due at a future date – eg an alert to book a follow up scan in one year.
I have been informed that EMIS does allow a future entry into a patient’s record (a diary date), but this must be for a specific clinical code and the only way to see that there is a due diary date entry is to access the patient’s record and view the summary page or diary section. Unless the GP has reason to inspect the patient’s clinical record and examine the summary or diary pages there is no way of being alerted that a new task needs to be completed for that patient . Further, it is not possible to add a pop-up linked diary date entry for a specific task (such as a scan) outside the EMIS determined list .
This creates a situation where the responsibility for ensuring that follow up investigations are undertaken at the correct time is placed onto the patient , and the patient will have to contact the GP to request follow-up.
In this case the Deceased was diligent in contacting his GP surgery to request repeat scans, but I consider that unless some action is taken there is a continuing risk of patients not contacting the GP to make a request for follow-up and therefore becoming lost to necessary follow-up .
” Open source report
21 May 2021 Dyllon Shaun Graham Milburn · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Lack of patient alerts for requesting and collecting repeat prescriptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dyllon Shaun Graham Milburn · 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
Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.
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× 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of patient alerts for requesting and collecting repeat prescriptions
Wider context from the report “The system for repeat prescriptions does not currently allow for alerts to be sent to a patient to remind them to request and collect their repeat prescription to encourage compliance.
” Open source report
4 Jan 2021 Pardeep Singh PLAHE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login View source Failure of EMIS consultation lists to update reliably View source Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Pardeep Singh PLAHE · 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
Pardeep Singh Plahe died at Queen Elizabeth Hospital on 12 August 2020 after inflicting a catastrophic injury to his neck with a decorative samurai sword. He had been increasingly concerned about a physical health complaint and had a scheduled GP telephone consultation that was missed because of a technical problem with the EMIS system. The report raised concerns that consultation lists could fail to update, creating a risk that urgent telephone consultations might be missed, and that the identified mitigation depended on practitioners remembering to log out and back in to the system.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update . Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment .
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of EMIS consultation lists to update reliably
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified . Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency .
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” Open source report
28 Feb 2020 Irene Whittingham · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Conflicting guidance on timing of Vitamin D and Calcium blood level monitoring View source Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses View source Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Irene Whittingham · 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
Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.
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× 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Conflicting guidance on timing of Vitamin D and Calcium blood level monitoring
Wider context from the report “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines.
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses
Wider context from the report “3. The WellSky and EMIS Software, had a confusing user drop down menu option , which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines .
” 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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment
Wider context from the report “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP , regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines .
” Open source report
17 Oct 2014 Yaser Saleh · Prevention of Future Deaths report Inner South London
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Concerns raised 1 Failure of computerised recall systems to identify chronic disease patients requiring review beyond current prescribing View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Yaser Saleh · 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
Yaser Saleh, aged 15, died on 13 September 2012 after collapsing with cardio-respiratory arrest from acute asthma. The report raised concerns that electronic systems did not identify asthma patients needing review when they were no longer receiving regular prescriptions, creating a risk of preventable deaths in people with chronic diseases.
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 Egton Medical Information Systems Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of computerised recall systems to identify chronic disease patients requiring review beyond current prescribing
Wider context from the report “The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review. Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication . She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report. The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy.
This risk of not identifying those at risk of death because they no longer comply or have not been prescribed treatment taken in the past brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring, are triggered for the attention of the GP, on wider criteria than current prescribing , or if such a system is available that the Department considers using it and other GPs are made aware of its use.
” 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