Recipient

Haughton Thornley Medical Centres

First report 25 Nov 2015•Latest report 25 Nov 2015

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: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 13

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

13stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

25 Nov2015
Manchester South
Concerns raised4
1. Failure to accurately record the professional identity of the clinician who assessed the patient
2. Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision
3. Failure to establish whether a patient fall was unwitnessed and its force and details
1. Failure to ascertain clinically significant chest symptoms from care staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Review medical records to ensure relevant information is recorded clearly.
  Stated planned
2. Action
  Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.
  Stated planned
3. Action
  Ensure all practice GPs undertake thoracic-trauma reading and attend relevant education.
  Stated planned
1. Action
  Present and discuss the incident at the relevant educational meeting to identify further changes.
  Stated planned
2. Action
  Adopt a lower threshold for seeking GP second opinions when clinicians have concerns.
  Stated completed
3. Action
  Complete a medical record-keeping course for GPs and reflect on its learning.
  Stated completed
4. Action
  Undertake personal reading and clinical updates on assessing and managing falls.
  Status unclear
5. Action
  Undertake personal reading, continuing professional development, and information gathering on thoracic trauma.
  Status unclear
AI-generated summary

Thomas Anthony Collins · 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

Thomas Anthony Collins lived in a care home and fell on 22 June 2015, sustaining chest injuries. He was not admitted to hospital at that time, was later admitted on 25 June, and died on 15 July 2015 after treatment for complications including sepsis, pneumonia and respiratory distress. The report raised concerns about paramedic decision-making and the GP’s assessment, including failures to recognise the seriousness of the injury and signs of a flail chest.

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 Haughton Thornley Medical Centres; that does not assign responsibility.
PFD Monitor interpretation
Failure to accurately record the professional identity of the clinician who assessed the patient
Wider context from the report
“2. The GP attended the patient on the 24th June and she assumed that he had been seen by a doctor on the 22nd because the record showed that he had been seen by a “practitioner”. In fact he had only been seen by the paramedic. This assumption very much detrimentally influenced her subsequent decision making.(Haughton Thornley Medical Centres) ”
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 Haughton Thornley Medical Centres; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision
Wider context from the report
“1. The attending paramedic lacked the confidence to make a clinical decision, which I accept can happen, but he then contacted the Out of Hours doctors who had no knowledge of the patient, rather than his own GP Practice. When, in what circumstances, should a paramedic seek the advice of a doctor who is not in attendance, as to whether the patient is to be taken to hospital?(NWAS) ”
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 Haughton Thornley Medical Centres; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish whether a patient fall was unwitnessed and its force and details
Wider context from the report
“3. On the attendance on the 24th, the doctor noted that the patient had had a fall, but she did not realise it was an unwitnessed fall, so the force and detail thereof was not known by anyone. She noted that the patient found it “was too painful for him to move or to sleep”, and she said it was “evident that he was in agony with pain for him to turn in bed” (sic). She did not ascertain from the care staff that the patient’s chest was “pulsating when breathing”, a classic sign of a flail chest. She conceded that facing the same situation now, she would have admitted him to hospital. This is clearly an area where further training is required.(Haughton Thornley Medical Centres) ”
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 Haughton Thornley Medical Centres; that does not assign responsibility.
PFD Monitor interpretation
Failure to ascertain clinically significant chest symptoms from care staff
Wider context from the report
“3. On the attendance on the 24th, the doctor noted that the patient had had a fall, but she did not realise it was an unwitnessed fall, so the force and detail thereof was not known by anyone. She noted that the patient found it “was too painful for him to move or to sleep”, and she said it was “evident that he was in agony with pain for him to turn in bed” (sic). She did not ascertain from the care staff that the patient’s chest was “pulsating when breathing”, a classic sign of a flail chest. She conceded that facing the same situation now, she would have admitted him to hospital. This is clearly an area where further training is required.(Haughton Thornley Medical Centres) ”
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
Review medical records to ensure relevant information is recorded clearly.

Verbatim wording from the response
“We will share this incident’s findings and learning with our local GP colleagues at the next local meeting, to help prevent further deaths of this nature occurring. We will also include an update of this incident in our next practice meeting. Our medical records will be reviewed to ensure that all of the relevant information is recorded clearly.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 3 · response
Published 25 November 2015
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
Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.

Verbatim wording from the response
“• When accidents happen in homes and care homes, we will ensure we record very clearly the findings and our rationale for not admitting the patient to hospital or transferring them to hospital. We will obtain more information surrounding the circumstances of a fall. The clinician who makes this decision will take responsibility for ensuring that the notes are complete and clear. We will ask for a detailed account from care home staff of witnessed falls and will obtain information from relatives where appropriate.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Ensure all practice GPs undertake thoracic-trauma reading and attend relevant education.

Verbatim wording from the response
“• All of the practice GPs will undertake personal reading and update their clinical knowledge of thoracic trauma and management of this area, and will also attend a relevant educational meeting. At this meeting, ███████ will present the case and discuss any further changes that can be made as a result (January 2016).”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Present and discuss the incident at the relevant educational meeting to identify further changes.

Verbatim wording from the response
“• All of the practice GPs will undertake personal reading and update their clinical knowledge of thoracic trauma and management of this area, and will also attend a relevant educational meeting. At this meeting, ███████ will present the case and discuss any further changes that can be made as a result (January 2016).”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Adopt a lower threshold for seeking GP second opinions when clinicians have concerns.

Verbatim wording from the response
“• We will have a lower threshold to speak to GP colleagues for a second opinion about patients if we have concerns (29 July 2015).”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Complete a medical record-keeping course for GPs and reflect on its learning.

Verbatim wording from the response
“• A medical record keeping course for GPs on the 6 October 2015 with subsequent reflection on the course.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Undertake personal reading and clinical updates on assessing and managing falls.

Verbatim wording from the response
“• Personal reading and updates on the assessment and management of falls (NICE CG 161: Guidance on the assessment and management of falls (2013)). There are no current local or national published guidelines on the management of falls at home or in care homes. This meeting may highlight further learning or educational needs with the GPs within the practice.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Undertake personal reading, continuing professional development, and information gathering on thoracic trauma.

Verbatim wording from the response
“• Updated clinical knowledge in the area of thoracic trauma with personal reading and CPD’s will undertake personal reading and information gathering.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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 raised4

Failure to accurately record the professional identity of the clinician who assessed the patient

Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision

Failure to establish whether a patient fall was unwitnessed and its force and details

Failure to ascertain clinically significant chest symptoms from care staff

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.8

Actions described in response 8