Old Bridge Surgery, Looe

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First report 22 Nov 2023•Latest report 22 Nov 2023

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 Old Bridge Surgery, Looe linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    David John Lewsey · 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

    David John Lewsey, aged 68, developed a pulmonary embolus following a left knee replacement and died after collapsing at home on 15 December 2022. Concerns included that severe side pain reported to reception staff was not passed to the advanced nurse practitioner, and that the pain’s location was not explored further. The report also raised whether staff training should better address chest or abdominal pain in recently immobilised post-operative patients.

    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 Old Bridge Surgery, Looe; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate staff training and assessment of chest or abdomen pain complaints

    Wider context from the report

    “- Evidence was heard at inquest that if the concern of a terrible pain in his side, reported in Mr Lewsy’s first telephone call to reception staff, had been passed on to the ANP, the initial discussion between Mr Lewsey and the ANP may have started down a different path. It was recognised that the doctors and nurses dealing with duty calls work under pressure, and it was felt that ensuring accurate and complete information was passed to them may reduce that pressure and facilitate the provision of a better service to patients. - The inquest also heard that reception staff had some training to raise a red flag if pain in the ‘chest’ was reported to them. Mr Lewsey said he had pain in his ‘side’ but the precise location of that pain was not explored further. While it was said in evidence that, typically, a PE will present with pleuritic or chest pain, it was noted that NICE guidance includes abdomen pain. You may wish to reflect on whether additional training is required for all staff on how to manage complaints of pain in the chest or abdomen particularly in patients who have recently undergone procedures that may have left them relatively immobile and at an increased risk of developing a DVT. ”
    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 Old Bridge Surgery, Looe; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to pass accurate and complete information from reception staff to clinicians handling duty calls

    Wider context from the report

    “- Evidence was heard at inquest that if the concern of a terrible pain in his side, reported in Mr Lewsy’s first telephone call to reception staff, had been passed on to the ANP, the initial discussion between Mr Lewsey and the ANP may have started down a different path. It was recognised that the doctors and nurses dealing with duty calls work under pressure, and it was felt that ensuring accurate and complete information was passed to them may reduce that pressure and facilitate the provision of a better service to patients. - The inquest also heard that reception staff had some training to raise a red flag if pain in the ‘chest’ was reported to them. Mr Lewsey said he had pain in his ‘side’ but the precise location of that pain was not explored further. While it was said in evidence that, typically, a PE will present with pleuritic or chest pain, it was noted that NICE guidance includes abdomen pain. You may wish to reflect on whether additional training is required for all staff on how to manage complaints of pain in the chest or abdomen particularly in patients who have recently undergone procedures that may have left them relatively immobile and at an increased risk of developing a DVT. ”
    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 Old Bridge Surgery, Looe; that does not assign responsibility.

    PFD Monitor interpretation

    NICE guidance not reflecting the use of LMWH with non-TED-stocking VTE prevention products

    Wider context from the report

    “The relevant NICE guidance may need to be updated to reflect the use of LMWH with products that assist with VTE prevention other than TED stockings. ”
    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

    Deliver whole-team training on telephone triage, call handling, flagging concerning calls, recording detail, and recognising atypical emergency presentations.

    Verbatim wording from the response

    “I reviewed the call recording of the initial call to reception. The whole Practice team then attended a training afternoon on Wednesday 6th December. As a major part of the training afternoon, we held a session on telephone triage and call handling.”

    Source location

    Response from Old Bridge Surgery
    Page 1 · response
    Published 28 November 2023

    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 the completeness of reception staff call details and present the results at a future training session within six months.

    Verbatim wording from the response

    “Our intention would be to audit in the future the fullness of details recorded by reception staff for calls added to the duty list and will present the results at a future training session within the next six months.”

    Source location

    Response from Old Bridge Surgery
    Page 1 · response
    Published 28 November 2023

    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