Recipient

Oakside Surgery

First report 8 Apr 2014•Latest report 8 Apr 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: 100%
Concerns addressed: 4
Stated actions: 6

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

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

8 Apr2014
Plymouth, Torbay and South Devon
Concerns raised5
1. Failure to ensure prompt treatment of suspected life-threatening conditions
2. Failure to conduct timely significant-events review of a death
3. Failure to ensure continuity of required anticoagulation medication
1. Failure to address suspected non-compliance with lifelong anticoagulation
2. Failure to check for omissions in anticoagulation treatment for other patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review advice given when patients begin anticoagulation.
  Stated completed
2. Action
  Discuss the entire case at the Practice’s September 2014 significant event analysis meeting.
  Stated planned
3. Action
  Extend the anticoagulation review to patients receiving low-molecular-weight heparin and novel oral anticoagulants.
  Stated planned
1. Action
  Audit all patients receiving acute or recurrent pulmonary-embolism treatment for similar omissions.
  Stated in progress
2. Action
  Compose a letter informing patients of the risks of non-concordance with medication.
  Stated in progress
Respondent positions 2
1. Position
  A patient with mental capacity could refuse hospital admission and treatment despite the risk of later harm.
  Disputes the concern
1. Position
  Pulmonary embolism should not be treated in the community without hospital investigations because anticoagulation could cause equally serious harm.
  Disputes the concern
AI-generated summary

Leslie Edmund Harding (Lez) · 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

Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

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 Oakside Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure prompt treatment of suspected life-threatening conditions
Wider context from the report
“1. ████████ took no action during the period from 18 – 28 September 2013. Patients with a suspected life-threatening condition (Pulmonary Embolus) must be promptly treated. The system for ensuring that the treatment is provided must be robust. That is particularly the case where it is already known that the patient suffers from an underlying condition that makes him prone to the particular life-threatening event. ”
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 Oakside Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct timely significant-events review of a death
Wider context from the report
“4. I was advised that this death had not yet been reviewed in a significant events meeting. In my view, that should have taken place forthwith after Lez’s death. You may wish to convene a significant events ”
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 Oakside Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure continuity of required anticoagulation medication
Wider context from the report
“3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. ”
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 Oakside Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to address suspected non-compliance with lifelong anticoagulation
Wider context from the report
“3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. ”
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 Oakside Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to check for omissions in anticoagulation treatment for other patients
Wider context from the report
“2. Your practice will have a number of other patients in receipt of anti-coagulation treatment following recurrent Pulmonary Embolii. Given the omission that appears to have occurred here, you need to ensure that no other omissions have happened with any of the other patients ”
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
Review advice given when patients begin anticoagulation.

Verbatim wording from the response
“3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 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
Discuss the entire case at the Practice’s September 2014 significant event analysis meeting.

Verbatim wording from the response
“4) I am relatively new to the Practice but my colleagues were able to produce evidence that the situation had been reviewed formally on a number of occasions and now we have your further report I have scheduled a further discussion of the entire case at the next significant event analysis meeting in the Practice which will take place in September 2014.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 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
Extend the anticoagulation review to patients receiving low-molecular-weight heparin and novel oral anticoagulants.

Verbatim wording from the response
“We have also decided to extend this review to patients receiving low molecular rate heparin and novel oral anti-coagulants.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 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
Audit all patients receiving acute or recurrent pulmonary-embolism treatment for similar omissions.

Verbatim wording from the response
“2) Having reviewed this case, I am undertaking an audit of all people receiving treatment for pulmonary emboli whether acute or recurrent to ensure that no similar omissions have occurred.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 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
Compose a letter informing patients of the risks of non-concordance with medication.

Verbatim wording from the response
“3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 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
A patient with mental capacity could refuse hospital admission and treatment despite the risk of later harm.

Verbatim wording from the response
“I did note that Mr Harding was judged to have mental capacity and that he appeared to have made an informed decision in the days leading up to the 18th September 2013 on more than one occasion not to be then admitted to hospital and received what I can consider to be the appropriate treatment. He appears to have made this decision in the knowledge that the outcome could have been fatal.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 1 · response
Published 8 April 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
Pulmonary embolism should not be treated in the community without hospital investigations because anticoagulation could cause equally serious harm.

Verbatim wording from the response
“I also feel that it would have been inappropriate for ████████ to have treated Mr Harding as if he had a pulmonary embolism within the community without appropriately investigating it with investigations which were only available within a hospital setting. If he had done so, this would”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 1 · response
Published 8 April 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 raised5

Failure to ensure prompt treatment of suspected life-threatening conditions

Failure to conduct timely significant-events review of a death

Failure to ensure continuity of required anticoagulation medication

Failure to address suspected non-compliance with lifelong anticoagulation

Failure to check for omissions in anticoagulation treatment for other patients

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.5

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 5

Respondent positions 2