Recipient

Hazelmere Medical Centre

First report 15 Dec 2016•Latest report 15 Dec 2016

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: 3
Stated actions: 1

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

1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

15 Dec2016
Leicester City and South Leicestershire
Concerns raised3
1. Failure to involve next of kin in significant decisions for a patient with declining cognitive function
2. Failure to record the rationale and patient consent for a change of GP
3. Failure to record consideration and outcome of the patient's capacity
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Capacity assessments are not routinely undertaken unless there is a medical need.
  Existing arrangements considered sufficient
1. Position
  There is usually no need to record the rationale for changing a patient's registered GP in the medical record.
  Existing arrangements considered sufficient
2. Position
  The medical records showed no cognitive decline requiring a formal capacity assessment, so capacity was assumed for the GP change process.
  Disputes the concern
AI-generated summary

Francis James Lea · 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

Francis James Lea, who was living in a care home, was transferred to a new GP without his family being informed. After a hospital admission for a seizure, his prescribed anti-epileptic medication was not continued because the new GP was unaware of the admission and prescription. The report raised concerns about involving next of kin, recording the rationale and consent or capacity assessment for changing GP, and ensuring a safe transfer of care between the care home and GP surgeries.

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 Hazelmere Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to involve next of kin in significant decisions for a patient with declining cognitive function
Wider context from the report
“(1) For a patient in a care situation, with declining cognitive function (as set out in his home care plan) it would seem appropriate to consider involving the next of kin in any significant decision such as change of GP. This would have enabled the family (who always ensured they accompanied Mr Lea for any medical care) to pass on the updated information, and this outcome would have been avoided. ”
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 Hazelmere Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to record the rationale and patient consent for a change of GP
Wider context from the report
“(2) There appeared to be no notes on the patient's medical record regarding the rationale for this change, or any consent from the patient that he was in agreement that it should take place. There was also no record of whether any consideration of his capacity had been undertaken, and if so what the outcome of that decision was. ”
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 Hazelmere Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to record consideration and outcome of the patient's capacity
Wider context from the report
“(2) There appeared to be no notes on the patient's medical record regarding the rationale for this change, or any consent from the patient that he was in agreement that it should take place. There was also no record of whether any consideration of his capacity had been undertaken, and if so what the outcome of that decision was. ”
Open source report
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
Capacity assessments are not routinely undertaken unless there is a medical need.

Verbatim wording from the response
“As highlighted the care home was facilitating change of GP and patients were offered the choice of declining to change their registered GP. As mentioned earlier it is not common practice to hold capacity assessment unless there is a medical need.”

Source location
2016-0447-Response-by-Hazelmere-Medical-Centre
Page 1 · response
Published 12 February 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
There is usually no need to record the rationale for changing a patient's registered GP in the medical record.

Verbatim wording from the response
“There is usually no need for documenting on patients medical records regarding rationale for change of GP.”

Source location
2016-0447-Response-by-Hazelmere-Medical-Centre
Page 1 · response
Published 12 February 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
The medical records showed no cognitive decline requiring a formal capacity assessment, so capacity was assumed for the GP change process.

Verbatim wording from the response
“The medical records of the patient do not reflect any evidence of declining cognitive function requiring the need for a formal capacity assessment. The communication with the care homes in this project of swapping care home patients between practices was explicit in stating that the change of registered GP was an active informed decision to be communicated to the patient, or if the care home felt there was a lack of capacity for this to be discussed with next of kin. As part of this project letters were written to the care home patients which was sent to Mr Lea as well detailing the above. Hence it was assumed that Mr Lea had capacity to engage in this process.”

Source location
2016-0447-Response-by-Hazelmere-Medical-Centre
Page 1 · response
Published 12 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 raised3

Failure to involve next of kin in significant decisions for a patient with declining cognitive function

Failure to record the rationale and patient consent for a change of GP

Failure to record consideration and outcome of the patient's capacity

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Respondent positions 3