Recipient

Premier Physical Healthcare

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First report 17 Oct 2015•Latest report 17 Oct 2015

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
3

Described in responses

Reports over time

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
3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. County Durham and Darlington

    AI-generated summary

    James Bewick Graham · 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

    James Bewick Graham, who had peripheral vascular disease and recurring problems with his left foot, was admitted to hospital after his condition deteriorated, underwent an amputation, and died on 2 November 2014. The report identified concerns about delayed referral to secondary care, poor communication between healthcare professionals, unclear responsibility for making the referral, and administrative failures that meant the referral was not dispatched.

    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 Premier Physical Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear ownership and responsibility for referrals to secondary care

    Wider context from the report

    “(2) The GP who had most contact with the deceased in a 2 year period considered making a referral to secondary care on 17th October 2014 and instead of making the referral himself, passed the responsibility to make a referral to another GP (who worked one day per week) and who had previously sent a one page letter of referral to secondary care more than 2 years earlier. The GP gave evidence that he thought it appropriate for the original GP to make the referral as that GP had done the first one and was acquainted with the matter. The second GP gave evidence to say that she did not agree with this action because although, in principle, if there had been a recent referral it might have been appropriate for the original referring GP to make a second referral however after 2 years it was “stretching it a bit”. There was a lack of ownership and responsibility for the deceased’s care and making a referral to secondary care. There needs to be consideration given to the formulation of clear guidance as to which GP and in what circumstances has a responsibility for referrals to secondary care. ”
    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 Premier Physical Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to dispatch secondary care referral letters

    Wider context from the report

    “(3) The GP who agreed to make a referral to secondary care gave evidence that she had wrote out a letter of referral and handed it to a member of the administrative team for typing and gave verbal instructions that this needed to be dealt with quickly and that if there were any problems she was to be contacted. For an unknown reason the letter of referral was not dispatched. Some consideration has been given to this issue following the publication of the PPO report but in the light of the evidence given in court the thoroughness and robustness of that letter of direction, particularly bearing in mind there have been a number of changes to the providers of healthcare in the prison, should be considered. ”
    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 Premier Physical Healthcare; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of communication between general practitioners and podiatrists during concurrent patient care

    Wider context from the report

    “(1) It is clear that on 16th October 2014 the deceased was seen by a general practitioner and a podiatrist at more or less the same time. The GP did not fully examine the deceased because he knew he was to see a podiatrist. The podiatrist discovered serious problems with the deceased’s foot and planned an urgent referral to the GP and did so by means of an electronic note which was seen by the GP who had seen the deceased immediately prior to the podiatrist, the day after, who then referred the matter to another GP to make a letter of referral and then because of administrative failures no referral to secondary care was made before the deceased died on 2nd November 2014. This shows a total lack of communication between the GP and the podiatrist who should have considered it appropriate to speak to one another whilst the deceased was still present in order to matters forward effectively. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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