31 Oct 2025 Gloria SIMON · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 5 Failure to ensure that practice staff are informed about the nature and status of resident institutions View source Failure to establish the clinical qualifications of staff observing or caring for care home residents View source Failure to establish the timing and need for repeat observations View source Failure to ensure face-to-face clinical assessment of vulnerable elderly patients View source Failure to obtain and consider relevant previous medical history View source See 2 more concerns
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Gloria SIMON · 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
Gloria Simon moved into a care home for respite on 9 September 2025 and died there from natural causes on 20 September after her condition deteriorated. Concerns included missed opportunities to obtain timely clinical input, the GP’s failure to undertake a face-to-face assessment after misreading oxygen saturation results, and insufficient attention to her medical history and care-home setting.
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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 Marine Lake Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that practice staff are informed about the nature and status of resident institutions
Wider context from the report “1. The GP to whom this case was allocated told the court that he did not know that Gloria Simon was in a care home setting (as opposed to a nursing home setting), which had no clinical staff of any kind, despite having previously visited the premises and despite the clerical assistant's note on a Consultation Report that this was a request from VCH’. He indicated that it was as a result of this misunderstanding was that he did not visit the premises to make a face-to-face clinical assessment.
The court is concerned that a recurrence of this situation could leave vulnerable elderly patients with inadequate care. The court would like to know whether measures are being taken to ensure that those in the practice are properly informed about the nature and status of resident institutions with whom they have contact .
” 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 Marine Lake Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the clinical qualifications of staff observing or caring for care home residents
Wider context from the report “2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’.
The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him.
There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting).
The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur.
” 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 Marine Lake Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the timing and need for repeat observations
Wider context from the report “2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’.
The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him.
There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting).
The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur.
” 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 Marine Lake Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure face-to-face clinical assessment of vulnerable elderly patients
Wider context from the report “1. The GP to whom this case was allocated told the court that he did not know that Gloria Simon was in a care home setting (as opposed to a nursing home setting), which had no clinical staff of any kind, despite having previously visited the premises and despite the clerical assistant's note on a Consultation Report that this was a request from VCH’. He indicated that it was as a result of this misunderstanding was that he did not visit the premises to make a face-to-face clinical assessment.
The court is concerned that a recurrence of this situation could leave vulnerable elderly patients with inadequate care. The court would like to know whether measures are being taken to ensure that those in the practice are properly informed about the nature and status of resident institutions with whom they have contact.
” 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 Marine Lake Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and consider relevant previous medical history
Wider context from the report “2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’.
The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him.
There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home ; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting).
The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur.
” 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 Reiterate to care homes the importance of providing a complete set of observations.
Verbatim wording from the response “It is noted on the request for care form that several of the parameters were missing. We will reiterate the importance of a full set of observation from staff to care homes, but accept that this may lie outside of the competence of some care home staff. We expect all Marine Lake clinicians to ensure they are comfortable with the clinical information available but not at the detriment of delaying appropriate assessment of the patient.” Source location Response from Marine Lake Medical Practice
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 clinicians assess whether available clinical information is sufficient without delaying appropriate patient assessment.
Verbatim wording from the response “It is noted on the request for care form that several of the parameters were missing. We will reiterate the importance of a full set of observation from staff to care homes, but accept that this may lie outside of the competence of some care home staff. We expect all Marine Lake clinicians to ensure they are comfortable with the clinical information available but not at the detriment of delaying appropriate assessment of the patient.” Source location Response from Marine Lake Medical Practice
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 Update the clinical induction pack with each care home’s residential, dual-status or nursing profile.
Verbatim wording from the response “Of note the request for care form does state “Riversdale Nursing Home”, which is incorrect and was completed by a Riversdale member of staff. As a result of our reflection, the form has been updated to include a question relating to whether a resident is in a residential bed or a nursing bed. The practice has a number of care homes some of which have dual care status patients. The clinical induction pack that is given to all new clinical practitioners has also been updated to give an overview to the general status of each home ie solely residential, dual status or predominantly nursing residents.” Source location Response from Marine Lake Medical Practice
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 Update the care request form to distinguish residential and nursing beds.
Verbatim wording from the response “Of note the request for care form does state “Riversdale Nursing Home”, which is incorrect and was completed by a Riversdale member of staff. As a result of our reflection, the form has been updated to include a question relating to whether a resident is in a residential bed or a nursing bed. The practice has a number of care homes some of which have dual care status patients. The clinical induction pack that is given to all new clinical practitioners has also been updated to give an overview to the general status of each home ie solely residential, dual status or predominantly nursing residents.” Source location Response from Marine Lake Medical Practice
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations