Recipient

Lime Tree Surgery, Leytonstone

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First report 19 Dec 2016•Latest report 19 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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
5

Described in responses

Reports over time

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
5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Lime Tree Surgery, Leytonstone linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to Lime Tree Surgery, Leytonstone (previous provider), now represented here by Lime Tree Surgery, Leytonstone.

    East London

    AI-generated summary

    Mr Terence Hawkins · 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

    Mr Terence Hawkins, an 88-year-old resident of St. Catherine’s Residential Care Home, became unresponsive after vomiting during the early hours of 12 May 2016 and was pronounced dead at 05:12. The concerns identified were that there was no system for regular medical monitoring of care-home residents and that Mr Hawkins had not been seen by a GP for many months.

    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 Lime Tree Surgery, Leytonstone; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a system for regular medical monitoring of care home residents

    Wider context from the report

    “1. There was no system in place for the regular medical monitoring of residents with the Care Home. Mr Hawkins had not been seen by a GP for many months. The Care Home Manager confirmed that it could be difficult for medical assessments to be arranged for residents within the home who are unable to attend the surgery. ”
    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

    Lower the threshold for requesting home visits from the care home following the significant event analysis.

    Verbatim wording from the response

    “In response to paragraph 7, I cannot see any justifiable action other than to strengthen the lines of communication between the care home staff and the surgery given that you have reported from the new manager difficulties in obtaining GP visits. The GP is the person who is delivering bits of service and the care home manager is the person to ensure the client gets what they have identified they need (SCIE survey, 2013 p12).⁵ I can assure you that there will be no difficulties in getting GP home visits. An in-house Significant Event Analysis was conducted on 18.5.2016 following the information”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    Page 4 · response
    Published 12 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

    Survey care-home visit requests and obtain feedback to identify improvements.

    Verbatim wording from the response

    “I will take this evidence as feedback from the home of their experience of visit requests. I will therefore conduct a survey of visit requests by the home and seek feedback on how to improve this experience. I will follow this up with designing a new pathway for requesting home visits incorporating and responding to this feedback. I will also monitor home visit requests for a period of time.”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    Page 1 · response
    Published 12 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

    Review the medical care of all care-home residents through multiple post-death clinical review visits.

    Verbatim wording from the response

    “Following the deceased’s death, the CCG highlighted to us their concerns about the Home as well as concerns expressed by CQC. They asked the GP to conduct a review of all the residents. Following these concerns several visits have been conducted by me to review all the residents medical care. The first medical review was carried out within 72hrs of Mr Hawkins death and the latest one in November 2016. There were no significant findings or new medical diagnoses following these visits. Significant procedural shortcomings and lack of care records were noted. Some of these related to hospital follow-ups, outstanding blood results and lack of nursing record keeping. These visits were not directly related to the deceased’s death but as a precaution given the concerns expressed by other bodies. I did not mention these visits in the inquest as they were not directly relevant to the death.”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    Page 4 · response
    Published 12 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

    Design a new home-visit request pathway incorporating the survey feedback.

    Verbatim wording from the response

    “I will take this evidence as feedback from the home of their experience of visit requests. I will therefore conduct a survey of visit requests by the home and seek feedback on how to improve this experience. I will follow this up with designing a new pathway for requesting home visits incorporating and responding to this feedback. I will also monitor home visit requests for a period of time.”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    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 evidence does not support regular GP visits as necessary or likely to prevent similar deaths.

    Verbatim wording from the response

    “You have mentioned in your letter to me that ‘there was concern in this case in relation to a lack of medical review. I have therefore prepared a report under regulation 28 of the coroners (investigation of deaths) regulations 2013’. The implication is that there is systematic lack of medical review due to lack of GP visits which needs rectifying to prevent future deaths. Your assumption is that the only way to rectify this is to arrange regular GP visits. I have a serious objection to such conclusion. The evidence presented to you does not support this view.”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    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

    Care home management is responsible for ensuring identified resident needs are communicated and addressed through appropriate care arrangements.

    Verbatim wording from the response

    “The level of medical care is only as good as the level of care and knowledge of the patient by the carers. Good GP care cannot be solely in the gift of the GP. The quality of care a GP can administer is highly dependent upon the quality of staff in the care home itself (Gladman, 2010 p.20).¹”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    Page 2 · 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

    Existing arrangements ensured clinically required home visits, alternative contact routes and advice to request reassessment after deterioration.

    Verbatim wording from the response

    “The manager states that it can take 2hrs to get through on the phone on a Monday to request a visit. Even if this was the case we have a dedicated safe haven fax machine to receive requests for visits as well as alternative contact numbers. At no point, has she stated that the GP refuses to visit when asked and clinically indicated. I think the failure clearly lies in the management systems in place at the home.”

    Source location

    2016-0454-Response-by-Lime-Tree-Surgery
    Page 1 · response
    Published 12 February 2017

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
40%60%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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