Recipient

Grosvenor Medical Centre

First report 8 Dec 2016•Latest report 5 Jun 2017

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: 2
Published responses: 100%
Concerns addressed: 5
Stated actions: 8

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

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

5 Jun2017
Manchester South
Concerns raised5
1. Failure to document or record therapy selection options and rationale
2. Lack of clarity of triggers for referrals other than group therapy
3. Failure to make referrals to sleep clinic services for insomnia
1. Lack of a clear formal escalation process for concerns held by health professionals
2. Limited information sharing between health professionals to identify service access and need for psychiatric referral
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
  Stated completed
2. Action
  Escalated the lack of local insomnia sleep-clinic provision and referral support to the Tameside and Glossop CCG mental health lead.
  Stated completed
3. Action
  Escalated concerns about inadequate mental health support for GPs to the Tameside CCG mental health leads.
  Stated completed
Respondent positions 1
1. Position
  Local insomnia sleep-clinic provision is unavailable, so referrals require distant services with substantial waiting times.
  Unable to act
AI-generated summary

David Ian Hamilton · 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

David Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.

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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to document or record therapy selection options and rationale
Wider context from the report
“1. Healthy Minds had no documentation or system of recording the selection process for therapy including the options given and rationale for the choice of therapy; ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity of triggers for referrals other than group therapy
Wider context from the report
“2. There was a lack of clarity of triggers for referrals other than group therapy; ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to make referrals to sleep clinic services for insomnia
Wider context from the report
“4. Referrals were not made to sleep clinic services to assist with insomnia ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear formal escalation process for concerns held by health professionals
Wider context from the report
“5. There was no evidence of a clear formal escalation process where concerns were held by a health professional ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Limited information sharing between health professionals to identify service access and need for psychiatric referral
Wider context from the report
“3. The system of sharing information between health professionals (the GP and Healthy Minds) to identify if the correct services were being accessed or if a referral to a psychiatrist was required was limited and meant that those involved did not have a full picture of his mental health; ”
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
Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.

Verbatim wording from the response
“3) We have also written to the Mental Health Lead to ask for improved communication between the Healthy Minds and the GPs.”

Source location
2017-0180-Response-by-Grosvenor-Medical-Centre
Page 2 · response
Published 4 August 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
Escalated the lack of local insomnia sleep-clinic provision and referral support to the Tameside and Glossop CCG mental health lead.

Verbatim wording from the response
“Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester. The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days. There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.”

Source location
2017-0180-Response-by-Grosvenor-Medical-Centre
Page 2 · response
Published 4 August 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
Escalated concerns about inadequate mental health support for GPs to the Tameside CCG mental health leads.

Verbatim wording from the response
“I attended the inquest on 01-06-17 and it is very helpful to have your report. I have since, fed back to my colleagues in the practice and also raised concerns about mental health support with colleagues in the Clinical Commissioning Group. Your report has also been read by all my colleagues. We have tried to address the concerns. The actions taken are as below:”

Source location
2017-0180-Response-by-Grosvenor-Medical-Centre
Page 1 · response
Published 4 August 2017
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
Local insomnia sleep-clinic provision is unavailable, so referrals require distant services with substantial waiting times.

Verbatim wording from the response
“Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester. The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days. There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.”

Source location
2017-0180-Response-by-Grosvenor-Medical-Centre
Page 2 · response
Published 4 August 2017
Open published response
8 Dec2016
Manchester South
Concerns raised7
1. Failure to undertake annual liver function tests
2. Failure to review CAF documentation
3. Lack of clarity about referral routes and acceptance by Psychological services
1. Delays in reporting EEGs
2. Delays in allocation of cases within Early Help Services
3. Lack of understanding of cases suitable for CAMHS referral
4. Lack of GP involvement in inter-agency case handling
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement annual liver-function monitoring for patients prescribed sodium valproate, with due-date alerts, prescription checks and escalation of missed tests.
  Stated completed
2. Action
  Route incoming CAF documents to the duty doctor for same-day action assessment, then scan and circulate them to regular GPs when no same-day response is required.
  Stated completed
3. Action
  Search current sodium-valproate patients’ records and invite those overdue for liver-function testing to attend for blood tests.
  Stated completed
AI-generated summary

Rachal Marie Murphy · 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

Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake annual liver function tests
Wider context from the report
“1. There was a failure to undertake annual liver function tests in 2014 and 2015 ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to review CAF documentation
Wider context from the report
“2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case. ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about referral routes and acceptance by Psychological services
Wider context from the report
“1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals. ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Delays in reporting EEGs
Wider context from the report
“3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest. ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Delays in allocation of cases within Early Help Services
Wider context from the report
“1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved. ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of understanding of cases suitable for CAMHS referral
Wider context from the report
“2. Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS. ”
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of GP involvement in inter-agency case handling
Wider context from the report
“2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case. ”
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
Implement annual liver-function monitoring for patients prescribed sodium valproate, with due-date alerts, prescription checks and escalation of missed tests.

Verbatim wording from the response
“1. The British National Formulary issue 72 advises that LFTs “should be checked before sodium valproate therapy is commenced and during the first 6 months of treatment, especially in patients most at risk”. Although the BNF does not advise checking LFTs annually for patients on sodium valproate, we all accept this would be good practice in view of the risk of hepatic dysfunction and have agreed to adopt this policy within the Practice.”

Source location
2016-0401-Response-by-Grosvenor-Medical-Centre
Page 1 · response
Published 19 February 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
Route incoming CAF documents to the duty doctor for same-day action assessment, then scan and circulate them to regular GPs when no same-day response is required.

Verbatim wording from the response
“CAF documents received through the post will now be given to the duty doctor on the day they arrive, to determine whether any action is required that day, such as responding to CAF meeting invitations, liaising with any other colleagues involved in the patient’s care or arranging any follow up required at the Practice. Should no same-day response be needed, the document is then scanned and sent to all regular GP’s at the practice to read, in order that they are all made aware of the information contained.”

Source location
2016-0401-Response-by-Grosvenor-Medical-Centre
Page 2 · response
Published 19 February 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
Search current sodium-valproate patients’ records and invite those overdue for liver-function testing to attend for blood tests.

Verbatim wording from the response
“I have done a search of the Practice list for all patients currently prescribed sodium valproate and noted when their last LFTs were checked. If this has not been within the last year, they have been sent a letter inviting them in for a blood test.”

Source location
2016-0401-Response-by-Grosvenor-Medical-Centre
Page 1 · response
Published 19 February 2017
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 raised5

Failure to document or record therapy selection options and rationale

Lack of clarity of triggers for referrals other than group therapy

Failure to make referrals to sleep clinic services for insomnia

Lack of a clear formal escalation process for concerns held by health professionals

Limited information sharing between health professionals to identify service access and need for psychiatric referral

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised7

Failure to undertake annual liver function tests

Failure to review CAF documentation

Lack of clarity about referral routes and acceptance by Psychological services

Delays in reporting EEGs

Delays in allocation of cases within Early Help Services

Lack of understanding of cases suitable for CAMHS referral

Lack of GP involvement in inter-agency case handling

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.3

Actions described in response 3

Respondent positions 1

Actions described in response 3