6 Feb 2026 Mr Stephen Martin Rhodes · Prevention of Future Deaths report Black Country
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Concerns raised 2 Failure to adequately scrutinise laboratory blood test results View source Failure to prominently flag abnormal laboratory results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Stephen Martin Rhodes · 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 Stephen Martin Rhodes, who had progressive shortness of breath, had a markedly raised NT-proBNP result that was filed in the mistaken belief that there was no abnormal finding. He collapsed and died after developing a cardiac arrest while working as a delivery driver on 11 March 2025. The principal concern was that the blood test result was not adequately scrutinised and the recommended specialist referral and echocardiography within two weeks did not occur; the inquest conclusion was narrative, with natural causes contributed to by neglect.
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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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately scrutinise laboratory blood test results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP . The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red.
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to prominently flag abnormal laboratory results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP. The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red .
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Open source report
14 Sep 2021 Siwan Llio SMITH · Prevention of Future Deaths report Gwent
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Concerns raised 1 Lack of awareness among reception staff of when patients require urgent clinical assessment for mental health concerns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Siwan Llio SMITH · 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
Siwan Smith had a long-standing history of anxiety and depression, which worsened during the Covid-19 pandemic, and she died by hanging at home on 23 November 2020. The report raised concern that, when she sought an earlier appointment and was distressed, reception staff did not identify whether she required urgent mental health support or arrange a call from a clinically trained person.
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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among reception staff of when patients require urgent clinical assessment for mental health concerns
Wider context from the report “1. Response to Mental Health Concerns by Reception Staff
During the course of the inquest, Mr Martin Smith, Siwan’s husband, raised concerns that on 18th November 2020, Siwan telephoned the Medical Centre to obtain an urgent appointment with a doctor. She was informed by the receptionist that the earliest appointment was on 30th November 2020.
The Medical Centre provided me with a report which indicated that when Siwan asked about whether there were any emergency appointments for mental health problems she was advised that these are not routinely offered unless a patient is having “bad thoughts”. Your report states that an emergency appointment was not requested and at no point was it suggested the call was a mental health emergency.
The Medical Centre provided me with a recording of the telephone exchange between Siwan and the receptionist. I found during the inquest that Siwan asked repeatedly if she could have an earlier appointment and was clearly upset that she could not. She was not asked if she was having bad thoughts or whether she required urgent mental health support. It was clear towards the end of the conversation that Siwan was distressed.
I also received in evidence a letter dated 8 March 2021 written By ████████, the Practice Manager to Mr Smith, in which she implies that the receptionists are not clinically trained to make assessments. I accept this, however in the circumstances I determined that Siwan should have received a call back from someone who was clinically trained to ascertain whether she required an urgent mental health assessment.
In the circumstances I did not find that a different course of action would have prevented Siwan’s death or would have altered the outcome. However I am concerned that lives could be put at risk in the future if there continues to be a lack of awareness of when a patient may require a clinical assessment in relation to their mental health.
” Open source report
4 Feb 2021 Jerome Alexander Peat · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure of the EMIS computer medical record to alert the medical centre to prior GP registration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jerome Alexander Peat · 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
Jerome Alexander Peat was found dead from an overdose of morphine at his student accommodation on 12 December 2019. The report identifies inadvertent duplication of morphine prescriptions, after the medical record failed to alert a practice that he had already registered with another GP, resulting in significantly more morphine being prescribed than intended.
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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of the EMIS computer medical record to alert the medical centre to prior GP registration
Wider context from the report “The EMIS computer medical record on 4.11.19 failed to alert ████████ at Long Furlong Medical Centre that Mr. Peat had already registered with the GP at the Student Medical Centre , as a result of which there was inadvertent duplication of his morphine prescription on 4.11.19 and 5.11.19 and Mr. Peat was prescribed significantly more morphine than was intended. He subsequently died from an overdose of prescribed morphine.
” Open source report
5 Dec 2018 Mrs Sylvia Mitchell · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Inadequate communication of the risks of delayed pessary removal View source Failure to provide routine pessary cleansing View source Failure to ensure proper pessary fitting View source Failure to monitor vaginal integrity during pessary use View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Sylvia Mitchell · 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
Mrs Sylvia Mitchell, a 90-year-old woman, died at Good Hope Hospital on 23 May 2018 after developing urosepsis associated with a fistula caused by an impacted Gellhorn pessary. The report identified inadequate communication and failures to adequately monitor and review the pessary, with delays in its removal contributing to her death.
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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of the risks of delayed pessary removal
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently .
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to provide routine pessary cleansing
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures .
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper pessary fitting
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting , routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor vaginal integrity during pessary use
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina . Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” Open source report
27 Mar 2018 Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 6 Failure to address cross-practice recurrence of mental health care coordination concerns View source Delays in delivery of mental health clinic letters to GPs View source Inability of GPs to implement rapid and accurate specialist-directed medication changes View source Failure of mental health referral routing between teams View source Lack of joint coordination between mental health and primary care services View source Failure of GP prescribing to follow psychiatric team direction View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maureen Anne CAMPBELL-SCOTT · 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
Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to address cross-practice recurrence of mental health care coordination concerns
Wider context from the report “(6) It is accepted that the concerns in this case are unlikely to be restricted to the Fulwell Cross Surgery . If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in delivery of mental health clinic letters to GPs
Wider context from the report “(2) There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust. Often, the clinic letters contained requests for the GP to make changes to medication.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Inability of GPs to implement rapid and accurate specialist-directed medication changes
Wider context from the report “(4) In times of acute mental health crisis, medication if often rapidly changed/supplemented. Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health referral routing between teams
Wider context from the report “(1) The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in Maureen Campbell-Scott receiving an assessment.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of joint coordination between mental health and primary care services
Wider context from the report “(5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP and the psychiatrist.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of GP prescribing to follow psychiatric team direction
Wider context from the report “(3) The prescribing by the GP did not always follow the direction given by the psychiatric team.
” Open source report
14 Jul 2016 Fred Whittaker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records View source Lack of standard directions for managing requests to restart a discontinued medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Fred Whittaker · 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
Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.
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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of standard directions for managing requests to restart a discontinued medication
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” Open source report
17 Jan 2014 JULIA SHEEREN DELL · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 4 Lack of formal handover when primary care responsibility changed View source Failure to act on a care plan received from the Community Mental Health Team View source Failure of primary care to maintain involvement and awareness of fluctuating mood View source Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JULIA SHEEREN DELL · 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
Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.
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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of formal handover when primary care responsibility changed
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to act on a care plan received from the Community Mental Health Team
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of primary care to maintain involvement and awareness of fluctuating mood
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012” . He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations