Hereford Medical Group

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First report 4 Oct 2023•Latest report 4 Oct 2023

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
Published responses: 100%
Concerns addressed: 4
Stated actions: 7

Concerns and recipient responses

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

4 Oct2023
Herefordshire
Concerns raised5
1. Failure to telephone patients as requested or advised
2. Failure of triage clinicians to be aware of routine appointment waiting times
3. Incomplete triage documentation
1. Unavailability of a revised protocol for triaging patients with mental health problems
2. Failure to consider telephone call transcripts during triage
Actions described in response 4
1. Action
  Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.
2. Action
  Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.
3. Action
  Implement a process allowing clinicians to listen to the patient’s phone call when an online triage form is unavailable.
1. Action
  Update reception protocols so receptionists telephone patients first to explain the GP’s triage decision.
Respondent positions 2
1. Position
  The existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.
  Existing arrangements considered sufficient
1. Position
  The telephone call contained nothing that would have influenced the GP’s triaging outcome.
  Disputes the concern
AI-generated summary

Ronald Leslie HARRIS · 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

Ronald Leslie Harris’s family contacted the practice in April 2023 about worsening mental health difficulties and requested further help, but a routine appointment was offered with a stated 4–6 week wait and no follow-up call was made. He died by suicide on 5 June 2023. Concerns included incomplete triage documentation, failure to make the requested call, and the triage doctor’s lack of awareness of the waiting time and the telephone-call transcript; a review of mental-health triage protocols was noted, but no revised protocol had been advised by the inquest.

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 Hereford Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to telephone patients as requested or advised
Wider context from the report
“(2) The patient was not telephoned as requested and as advised they would be. ”
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 Hereford Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Failure of triage clinicians to be aware of routine appointment waiting times
Wider context from the report
“(3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. ”
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 Hereford Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Incomplete triage documentation
Wider context from the report
“(1) Triage documentation was not fully completed. ”
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 Hereford Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of a revised protocol for triaging patients with mental health problems
Wider context from the report
“(4) The Deceased died on the 5th June 2023. The Inquest was told that a significant event meeting on the 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken. The Inquest was held on the 27th September 2023 no revised protocol was advised. ”
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 Hereford Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider telephone call transcripts during triage
Wider context from the report
“(3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. ”
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
Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.

Verbatim wording from the response
“We have taken significant measures to reduce the wait time for routine appointments by increasing the number of available routine appointments. The wait for a routine appointment is under continuous review and our current wait is around approximately 4 weeks. In future, this information will be communicated to all staff on a weekly basis using the staff newsletter.”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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
Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.

Verbatim wording from the response
“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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
Implement a process allowing clinicians to listen to the patient’s phone call when an online triage form is unavailable.

Verbatim wording from the response
“We also noted learning from this event and have since implemented a new process whereby if an online form was not available for a clinician, they are able to arrange to listen to the phone call.”

Source location
Response from Hereford Medical Group
Page 1 · response
Published 18 October 2023
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
Update reception protocols so receptionists telephone patients first to explain the GP’s triage decision.

Verbatim wording from the response
“When patients complete a triage form they are asked to indicate their preference for contact including phone or SMS. We have updated the protocols that the team follows and the reception team, who usually undertake the actions indicated following triage, now telephone the patient in the first instance to advise on the GPs triage decision.”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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 existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.

Verbatim wording from the response
“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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 telephone call contained nothing that would have influenced the GP’s triaging outcome.

Verbatim wording from the response
“All triaging GPs are aware of how to find appropriate triage appointments. Calls are not routinely transcribed at the practice; when the Significant Event Analysis (SEA) meeting took place we ensured that a copy of the transcription was available to confirm what the receptionist advised was reflected in the call. We believe that nothing was discussed in the telephone call that would have influenced the triaging outcome.”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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 telephone patients as requested or advised

Failure of triage clinicians to be aware of routine appointment waiting times

Incomplete triage documentation

Unavailability of a revised protocol for triaging patients with mental health problems

Failure to consider telephone call transcripts during triage

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.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 4

Respondent positions 2