25 Nov 2015 Thomas Anthony Collins · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to accurately record the professional identity of the clinician who assessed the patient View source Failure to seek clinical advice from a doctor with knowledge of the patient when making a hospital-transfer decision View source Failure to establish whether a patient fall was unwitnessed and its force and details View source Failure to ascertain clinically significant chest symptoms from care staff View source See 1 more concern
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
Action
Review medical records to ensure relevant information is recorded clearly.
View source
Action
Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.
View source
Action
Ensure all practice GPs undertake thoracic-trauma reading and attend relevant education.
View source
Action
Present and discuss the incident at the relevant educational meeting to identify further changes.
View source
Action
Adopt a lower threshold for seeking GP second opinions when clinicians have concerns.
View source
Action
Complete a medical record-keeping course for GPs and reflect on its learning.
View source
Action
Undertake personal reading and clinical updates on assessing and managing falls.
View source
Action
Undertake personal reading, continuing professional development, and information gathering on thoracic trauma.
View source See 5 more actions
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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.
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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 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
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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 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
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 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
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 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
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 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
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 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
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 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
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 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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations