Recipient

NHS Leeds West Clinical Commissioning Group

First report 23 Jun 2014•Latest report 23 Jun 2014

Recipient record

Reports, concerns and published responses

Health and care · Clinical commissioning group. 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: 2
Stated actions: 2

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

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

23 Jun2014
West Yorkshire Eastern
Concerns raised3
1. Failure to identify urgent presentations requiring immediate hospital referral
2. Unavailability of a doctor to respond to genuine emergencies during routine surgery closures
3. Failure to provide advance, clear and specific notice of GP surgery closures
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Send a joint letter to Leeds practices reminding them of obligations for safe cover and clear urgent-care communications during training closures.
  Stated planned
2. Action
  Make a statement at a centrally organised TARGET event in each Leeds CCG reiterating obligations and recommendations for safe access during training closures.
  Stated planned
Respondent positions 1
1. Position
  NHS England is responsible for enforcing practices’ contractual obligations, including medical cover during training closures.
  Redirects responsibility
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

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 raised3

Failure to identify urgent presentations requiring immediate hospital referral

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

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

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.2

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 2

Respondent positions 1