Recipient

Meanwood Group Practice

First report 10 Dec 2024•Latest report 10 Dec 2024

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: 4
Stated actions: 20

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

20stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

10 Dec2024
West Yorkshire Eastern
Concerns raised5
1. Failure to follow the lower limb framework
2. Failure to make appropriate tissue viability referrals
3. Failure to support patients with wound self-management or regular appointment attendance
1. Inadequate systems for timely review of patient safety incidents and learning from findings
2. Failure to escalate concerns about deteriorating wounds
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Audit patients receiving regular practice wound care monthly, moving to three-monthly audits once the system is assured.
  Stated completed
2. Action
  Hold regular multidisciplinary discussions for complex or non-healing wounds and record outcomes in patient records.
  Stated planned
3. Action
  Adopt four-week escalation triggers for non-improving foot and leg wounds, including podiatry or Tissue Viability referral consideration.
  Stated planned
1. Action
  Update GP and practice nursing knowledge, training and wound-care processes in line with Leeds guidelines.
  Stated in progress
2. Action
  Complete and discuss a full significant event analysis of the case.
  Stated completed
3. Action
  Use a detailed wound-care template for relevant consultations, including four-week completion and photographic documentation.
  Stated completed
4. Action
  Review the Tissue Viability referral process to prevent inappropriate rejection of referrals.
  Stated completed
5. Action
  Apply a lower threshold for completing significant event analyses, discussing them weekly and recording and acting on lessons.
  Stated planned
Respondent positions 1
1. Position
  Long-term wound care will be referred to specialist services, with the ICB expected to commission the necessary service.
  Redirects responsibility
AI-generated summary

Karen Lesley Day · 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

Karen Lesley Day sustained a leg laceration in 2021 and received care from her GP practice and district nursing team. She was later admitted to hospital extremely unwell, did not respond to active treatment, and died on 14 July 2022. Concerns were raised that the lower limb framework was not followed consistently, referrals and escalation were inadequate, and the practice lacked adequate systems for timely internal investigation of patient safety incidents.

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 Meanwood Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow the lower limb framework
Wider context from the report
“(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again. ”
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 Meanwood Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to make appropriate tissue viability referrals
Wider context from the report
“(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again. ”
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 Meanwood Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to support patients with wound self-management or regular appointment attendance
Wider context from the report
“(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again. ”
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 Meanwood Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Inadequate systems for timely review of patient safety incidents and learning from findings
Wider context from the report
“(2) During the inquest I received evidence that the practice had not carried out any internal investigation in relation to this death and the practice accepted it should have done. I am concerned that the practice does not have adequate systems in place to ensure that patient safety incidents are reviewed in a timely way to allow lessons to be drawn from the findings. ”
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 Meanwood Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate concerns about deteriorating wounds
Wider context from the report
“(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again. ”
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
Audit patients receiving regular practice wound care monthly, moving to three-monthly audits once the system is assured.

Verbatim wording from the response
“• To audit all patients receiving regular wound care within the practice every month, and once the system is assured every 3 months.”

Source location
Response from Meanwood Group Practice
Page 2 · response
Published 11 December 2024
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
Hold regular multidisciplinary discussions for complex or non-healing wounds and record outcomes in patient records.

Verbatim wording from the response
“• We will hold regular multi-disciplinary team discussions for patients with complex or wounds that are failing to heal. The lead nurse to bring forward patients the nurses are concerned about. The result of the MDT will be recorded in the patient’s record.”

Source location
Response from Meanwood Group Practice
Page 2 · response
Published 11 December 2024
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
Adopt four-week escalation triggers for non-improving foot and leg wounds, including podiatry or Tissue Viability referral consideration.

Verbatim wording from the response
“• The practice will adopt a process that all foot wounds that have shown no improvement or are static within four weeks would trigger a review and referral to podiatry and all leg wounds that have shown no improvement should be reviewed and considered for referral to the Tissue Viability service.”

Source location
Response from Meanwood Group Practice
Page 2 · response
Published 11 December 2024
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 GP and practice nursing knowledge, training and wound-care processes in line with Leeds guidelines.

Verbatim wording from the response
“Following the inquest the case was discussed again at a practice meeting on 2nd December 2024 with all partners, salaried GPs and GP registrars, practice manager and deputy, practice nurse lead and reception manager and a full significant event analysis was presented and discussed. This led to the use of a detailed wound care template for all relevant wound management consultations, a review of the use of Tissue Viability Team referral process to ensure no other referrals are rejected, and GPs and the practice nursing team updating their knowledge, training and processes for wound care, in line with Leeds guidelines.”

Source location
Response from Meanwood Group Practice
Page 1 · response
Published 11 December 2024
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
Complete and discuss a full significant event analysis of the case.

Verbatim wording from the response
“The case had previously been discussed at a practice meeting on 25th July 2022 following the death of Ms Day. This is done for all patient deaths, and includes GPs, practice manager, practice pharmacist, and lead practice nurse. As with other case reviews it provided an opportunity to review and learn from the case.”

Source location
Response from Meanwood Group Practice
Page 1 · response
Published 11 December 2024
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
Use a detailed wound-care template for relevant consultations, including four-week completion and photographic documentation.

Verbatim wording from the response
“Following the inquest the case was discussed again at a practice meeting on 2nd December 2024 with all partners, salaried GPs and GP registrars, practice manager and deputy, practice nurse lead and reception manager and a full significant event analysis was presented and discussed. This led to the use of a detailed wound care template for all relevant wound management consultations, a review of the use of Tissue Viability Team referral process to ensure no other referrals are rejected, and GPs and the practice nursing team updating their knowledge, training and processes for wound care, in line with Leeds guidelines.”

Source location
Response from Meanwood Group Practice
Page 1 · response
Published 11 December 2024
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 Tissue Viability referral process to prevent inappropriate rejection of referrals.

Verbatim wording from the response
“Following the inquest the case was discussed again at a practice meeting on 2nd December 2024 with all partners, salaried GPs and GP registrars, practice manager and deputy, practice nurse lead and reception manager and a full significant event analysis was presented and discussed. This led to the use of a detailed wound care template for all relevant wound management consultations, a review of the use of Tissue Viability Team referral process to ensure no other referrals are rejected, and GPs and the practice nursing team updating their knowledge, training and processes for wound care, in line with Leeds guidelines.”

Source location
Response from Meanwood Group Practice
Page 1 · response
Published 11 December 2024
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
Apply a lower threshold for completing significant event analyses, discussing them weekly and recording and acting on lessons.

Verbatim wording from the response
“• The practice will have a lower threshold to complete a full significant event analysis. These will be discussed in the weekly practice clinical meeting and any lessons learnt recorded and acted on.”

Source location
Response from Meanwood Group Practice
Page 3 · response
Published 11 December 2024
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
Long-term wound care will be referred to specialist services, with the ICB expected to commission the necessary service.

Verbatim wording from the response
“• The practice will inform the ICB in Leeds of its intention to no longer provide long-term wound care management and would refer all relevant patients to a specialist service for wound care management. The practice would expect the ICB to commission the necessary service.”

Source location
Response from Meanwood Group Practice
Page 3 · response
Published 11 December 2024
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 follow the lower limb framework

Failure to make appropriate tissue viability referrals

Failure to support patients with wound self-management or regular appointment attendance

Inadequate systems for timely review of patient safety incidents and learning from findings

Failure to escalate concerns about deteriorating wounds

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.8

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 8

Respondent positions 1