Recipient

Grange Clinic

First report 6 Mar 2018•Latest report 6 Mar 2018

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

6 Mar2018
Gwent
Concerns raised6
1. Lack of effective and robust long-term care planning and clinical oversight
2. Delays in triaging emergency appointments resulting in insufficient attendance notice
3. Failure to prominently record severe or life-threatening asthma on medical notes
1. Lack of support for staff who challenge clinical decisions or seek second opinions
2. Failure to ensure continuity and availability of triage information for emergency appointment clinicians
3. Failure to provide clinical assessment and safeguarding advice when late patients attend emergency appointments
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.
AI-generated summary

ELLIE MAY CLARK · 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

Ellie May Clark was a child with severe asthma who became seriously unwell after attending her GP surgery and was later found to have died from bronchial asthma. The report identified concerns about care planning, triage delays and systems, her being turned away from an emergency appointment without clinical assessment or safeguarding advice, the recording of her severe asthma, and staff support when challenging decisions.

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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective and robust long-term care planning and clinical oversight
Wider context from the report
“(1) The lack of an effective and robust care plan. No one clinician was allocated to oversee the long-term management and care of Ellie's medical condition. She dealt with by three different doctors at the surgery within a period of 5 days leading up to her death. ”
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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Delays in triaging emergency appointments resulting in insufficient attendance notice
Wider context from the report
“(3) A delay in Ellie being triaged for an emergency appointment resulting in insufficient notice being given to ████████ to enable timely attendance at the appointment. ”
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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Failure to prominently record severe or life-threatening asthma on medical notes
Wider context from the report
“(5) A note that Ellie had severe/life threatening asthma was not placed on her medical notes in a prominent position. ”
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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Lack of support for staff who challenge clinical decisions or seek second opinions
Wider context from the report
“(6) Support staff did not feel they would be supported if they challenged a doctor's decision or sought a second opinion. ”
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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure continuity and availability of triage information for emergency appointment clinicians
Wider context from the report
“(4) The lack of an effective and robust triage system. The receptionist who spoke with ████████ on the telephone and the doctor who triaged Ellie were different to the receptionist ████████ spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment. ”
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 Grange Clinic; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide clinical assessment and safeguarding advice when late patients attend emergency appointments
Wider context from the report
“(2) Ellie was turned away from an emergency appointment for being late without any clinical assessment or safeguarding advice being given. ”
Open source report

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 raised6

Lack of effective and robust long-term care planning and clinical oversight

Delays in triaging emergency appointments resulting in insufficient attendance notice

Failure to prominently record severe or life-threatening asthma on medical notes

Lack of support for staff who challenge clinical decisions or seek second opinions

Failure to ensure continuity and availability of triage information for emergency appointment clinicians

Failure to provide clinical assessment and safeguarding advice when late patients attend emergency appointments