Recipient

North Shore Surgery

First report 17 Jun 2014•Latest report 17 Jun 2014

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: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from North Shore Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

17 Jun2014
Manchester South
Concerns raised6
1. Failure by the GP to examine the patient’s legs
2. Failure to arrange District Nurse attendance to redress the legs
3. Failure by the District Nursing service to treat necrotic ulcers appropriately
1. Failure by the GP practice to recognise the severity of leg ulceration
2. Failure by the District Nursing service to appreciate necrotic ulcers
3. Failure to organise transport for hospital outpatient appointments
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

AUDREY VERA GARLAND · 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

Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.

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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure by the GP to examine the patient’s legs
Wider context from the report
“4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs. ”
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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to arrange District Nurse attendance to redress the legs
Wider context from the report
“4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs. ”
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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure by the District Nursing service to treat necrotic ulcers appropriately
Wider context from the report
“2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering. ”
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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure by the GP practice to recognise the severity of leg ulceration
Wider context from the report
“1. There was a failure by the GP practice to recognise or fully appreciate the severity of the ulceration to her legs. ”
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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure by the District Nursing service to appreciate necrotic ulcers
Wider context from the report
“2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering. ”
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 North Shore Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to organise transport for hospital outpatient appointments
Wider context from the report
“3. Despite the fact that she was considered to be in need of an outpatient appointment at Blackpool Hospital on two separate occasions, this did not take place because no-one organised transport for her to get to and from the hospital. ”
Open source report

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 raised6

Failure by the GP to examine the patient’s legs

Failure to arrange District Nurse attendance to redress the legs

Failure by the District Nursing service to treat necrotic ulcers appropriately

Failure by the GP practice to recognise the severity of leg ulceration

Failure by the District Nursing service to appreciate necrotic ulcers

Failure to organise transport for hospital outpatient appointments