NHS Leeds West Clinical Commissioning Group

Health and care · Clinical commissioning group

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First report 23 Jun 2014•Latest report 23 Jun 2014

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
2

Across all linked responses

Stated actions
2

Described in responses

Concerns and recipient responses

Statements from NHS Leeds West Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    JOAN DOROTHY RICHARDSON · 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

    Joan Dorothy Richardson became seriously unwell with rapid swelling, bruising and discolouration of her arm. After her GP surgery was closed for staff training on 21 November 2013, she was seen the following day, suffered a cardiac arrest in hospital, and died; the cause of death was streptococcal toxic shock syndrome. The concerns were that emergency medical cover and clear arrangements for patients should be available when GP surgeries close for training, and that the delay of almost 24 hours contributed to the outcome.

    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 NHS Leeds West Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify urgent presentations requiring immediate hospital referral

    Wider context from the report

    “(5) No criticism is made that a precise diagnosis was not made. Nevertheless had Ms Richardson been seen on the 21st November 2013 it would have been obvious that she was extremely unwell and that her presentation was urgent and that time was of the essence and that she should have been referred to hospital immediately. ”
    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 NHS Leeds West Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a doctor to respond to genuine emergencies during routine surgery closures

    Wider context from the report

    “(3) On the occasions where there is a genuine emergency as there clearly was here, a Doctor should be available to deal with such an emergency notwithstanding that the surgery is closed for routine work, particularly when the training session is within normal surgery hours. ”
    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 NHS Leeds West Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide advance, clear and specific notice of GP surgery closures

    Wider context from the report

    “(2) This should be advertised well in advance by notices in the waiting area and in the entrances to the surgery with clear and specific instructions so that patients can seek emergency treatment elsewhere. ”
    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

    Send a joint letter to Leeds practices reminding them of obligations for safe cover and clear urgent-care communications during training closures.

    Verbatim wording from the response

    “I have discussed the recommendations of your report with my colleagues, the Medical Directors of Leeds South & East CCG and Leeds North CCG, and we have agreed the following:”

    Source location

    2014-0276-Response-by-Leeds-West-Clinical-Commissioning-Group
    Page 2 · response
    Published 23 June 2014

    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

    Make a statement at a centrally organised TARGET event in each Leeds CCG reiterating obligations and recommendations for safe access during training closures.

    Verbatim wording from the response

    “I have discussed the recommendations of your report with my colleagues, the Medical Directors of Leeds South & East CCG and Leeds North CCG, and we have agreed the following:”

    Source location

    2014-0276-Response-by-Leeds-West-Clinical-Commissioning-Group
    Page 2 · response
    Published 23 June 2014

    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

    NHS England is responsible for enforcing practices’ contractual obligations, including medical cover during training closures.

    Verbatim wording from the response

    “Please accept my apologies for the delay in this response but, as you will be aware, I believed it was necessary to address four concerns raised in your report for me to coordinate a response, not just on behalf of NHS Leeds West Clinical Commissioning Group (the CCG), but also from NHS England (West Yorkshire Area Team). The latter organisation is responsible for the contractual obligations and performance of general practitioners and also for dealing with formal complaints when addressed to several parts of the NHS as in this case. The CCG is responsible, among other things, for supporting quality improvement in general practice which includes the commissioning of staff training as well as the necessary medical cover provided to maintain safe access to care for patients during training sessions.”

    Source location

    2014-0276-Response-by-Leeds-West-Clinical-Commissioning-Group
    Page 1 · response
    Published 23 June 2014

    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