Lower Clapton Group Practice

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First report 7 May 2021•Latest report 7 May 2021

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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
7

Described in responses

Concerns and recipient responses

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

  1. Inner North London

    AI-generated summary

    Macaulay WILSON · 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

    Macaulay Wilson had a long-term indwelling urinary catheter that was not changed for almost a year, despite the catheter reportedly needing replacement every 12 weeks. The inquest determined that the failure to change it caused urosepsis. Concerns included failures by the hospital urology department to risk assess and arrange appropriate catheter changes, district nurses not enquiring about catheter changes, and unclear communication by the GP practice.

    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 Lower Clapton Group Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use specific language distinguishing catheter change from catheter care in requests

    Wider context from the report

    “The Homerton University Hospital urology clinical nurse specialist wrote to your practice on 18 February 2019, and included within the letter a request that you arrange for district nurses to change Mr Wilson’s indwelling catheter in 12 weeks. A doctor from your practice did consider the letter, did action it and did write to the district nurses, but did not include a specific request for catheter change (as opposed to catheter care, which does not include change of the catheter). It seems that your doctors’ use of language in this situation would benefit from further consideration. ”
    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

    Highlight instructions for other clinical teams and send the original correspondence with onward referrals.

    Verbatim wording from the response

    “Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data.”

    Source location

    2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
    Page 1 · response
    Published 18 May 2021

    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

    Communicate the revised processes to the team and incorporate them into the induction programme.

    Verbatim wording from the response

    “We have communicated the above to all members of the team including the person responsible for coding incoming patient related correspondence and these processes have been incorporated into our induction program. We have informed our local medicines management team about this case to ensure they can disseminate this risk within their monthly newsletter so that other practices can ensure a similar event does not occur. We have reported the incident via the National Reporting and Learning System and have informed the CCG. We are amending the City and Hackney wide EMIS template which is used when visiting housebound and vulnerable patients to include parameters such as catheters and catheter change as well as other issues which may increase patient risk such as pressure sores and falls.”

    Source location

    2021-0146-Response-from-Lower-Clapton-Group-Practice-Redacted
    Page 1 · response
    Published 18 May 2021

    Open published response
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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