Grasmere SurgeryIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 8 Sep 2017•Latest report 8 Sep 2017

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
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
3

Described in responses

Concerns and recipient responses

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

  1. Addressed to: The Senior Partner, The Grasmere Surgery, Leigh Health Centre, The Avenue, Leigh.

    Manchester West

    AI-generated summary

    Terence Ryan · 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

    Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.

    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 Grasmere Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of alerts for new medications subject to repeat prescription

    Wider context from the report

    “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016. The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:- a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment. b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time. However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked. ”
    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 Grasmere Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to notify relevant support services and contacts after patient self-discharge

    Wider context from the report

    “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. ”
    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 Grasmere Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record externally requested new medications on repeat prescriptions

    Wider context from the report

    “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016. The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:- a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment. b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time. However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked. ”
    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 Grasmere Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a protocol for patients self-discharging from hospital without necessary medication

    Wider context from the report

    “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. ”
    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

    Study and discuss the repeat prescribing and scanning protocols at a practice meeting.

    Verbatim wording from the response

    “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    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

    Arrange a follow-up meeting in three months to review how the prescribing protocol is working within the practice.

    Verbatim wording from the response

    “A further meeting will be arranged in three month's time to review how the Prescribing Protocol has been working within the Practice.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    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

    Meet with all receptionists and nurses to address the protocols.

    Verbatim wording from the response

    “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    Open published response
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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