3 Dec 2021 Alexander George Theodossiadis · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 10 Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis View source Failure to communicate identified falls risk to the receiving ward View source Failure to assess falls risk in confused hospital patients View source Failure to obtain sufficient information to assess appointment urgency and priority View source Absence of a clear pathway to an appropriate treatment location View source Absence of clear national leadership on lumbar puncture practice in meningitis View source Failure to provide written handover instructions or briefing notes during hospital transfer View source Absence of directions specifying action timetables for life-threatening conditions View source Insufficiently frequent refresher training for GP receptionists View source Failure to provide a nurse escort during transfer of severely unwell and confused patients View source See 7 more concerns
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Alexander George Theodossiadis · 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
Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.
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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission ; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate identified falls risk to the receiving ward
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out. In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls . He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to assess falls risk in confused hospital patients
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out . In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls. He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient information to assess appointment urgency and priority
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time . He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request . Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear pathway to an appropriate treatment location
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location ; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Absence of clear national leadership on lumbar puncture practice in meningitis
Wider context from the report “(3) The Inquest heard evidence that practice differs nationally on the need for a lumbar puncture in cases of meningitis . The absence of clear leadership on this issue nationally does not assist clinicians who may encounter this relatively rare, but serious condition.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written handover instructions or briefing notes during hospital transfer
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him , in breach of the prevailing Trust handover guidance .
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Absence of directions specifying action timetables for life-threatening conditions
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition .
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Insufficiently frequent refresher training for GP receptionists
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time. He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request. Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians.
” 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 One Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a nurse escort during transfer of severely unwell and confused patients
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort , nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations