One Medical Group

Health and care · Independent healthcare provider

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First report 3 Dec 2021•Latest report 3 Dec 2021

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

3 Dec2021
West Yorkshire Eastern
Concerns raised10
1. Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis
2. Failure to communicate identified falls risk to the receiving ward
3. Failure to assess falls risk in confused hospital patients
1. Failure to obtain sufficient information to assess appointment urgency and priority
2. Absence of a clear pathway to an appropriate treatment location
3. Absence of clear national leadership on lumbar puncture practice in meningitis
4. Failure to provide written handover instructions or briefing notes during hospital transfer
5. Absence of directions specifying action timetables for life-threatening conditions
6. Insufficiently frequent refresher training for GP receptionists
7. Failure to provide a nurse escort during transfer of severely unwell and confused patients
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

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

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 raised10

Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis

Failure to communicate identified falls risk to the receiving ward

Failure to assess falls risk in confused hospital patients

Failure to obtain sufficient information to assess appointment urgency and priority

Absence of a clear pathway to an appropriate treatment location

Absence of clear national leadership on lumbar puncture practice in meningitis

Failure to provide written handover instructions or briefing notes during hospital transfer

Absence of directions specifying action timetables for life-threatening conditions

Insufficiently frequent refresher training for GP receptionists

Failure to provide a nurse escort during transfer of severely unwell and confused patients