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First report 20 May 2015•Latest report 20 May 2015

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Inner North London

    AI-generated summary

    Viola Burke · 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

    Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on asthma pump use as a significant diagnostic tool

    Wider context from the report

    “(1) In the absence of a diagnosis of asthma, no questions had been asked about the reason for the use of the asthma pump, and it’s use became a significant diagnostic tool for the GP Out of Hours Service. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure identified vulnerable patients possess care plans

    Wider context from the report

    “(2) The GP practice had implemented a system for care plans to be held by identified vulnerable patients to ensure that the Out of Hours Service had full access to the medical records so as to avoid unnecessary hospital admission. Viola appeared in the GP list of such patients but had no care plan in her possession of the 4 January when the call was made to the CHUHSE. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to raise care-plan provision during subsequent patient contacts

    Wider context from the report

    “(3) Evidence was given at the inquest that Viola had been sent an invitation letter on 1 October 2014 to attend the surgery for the care plan. When Viola did not respond the GP receptionist is reported to have made three unanswered telephone calls to Viola’s landline number. The GP consultation record produced at inquest stated ‘Admission avoidance care ended’. The records also showed that Viola attended the surgery with her son on 5 October, and on two further occasions during October on the 11th and 21st. Her daughter is also seen to have telephoned on the 30th. Viola then has eight monitoring entries in November and four in December 2014. At no point was the matter of the Care Plan raised with her. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ask about the reason for asthma pump use

    Wider context from the report

    “(1) In the absence of a diagnosis of asthma, no questions had been asked about the reason for the use of the asthma pump, and it’s use became a significant diagnostic tool for the GP Out of Hours Service. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear arrangements for keeping care plans up to date

    Wider context from the report

    “(4) Evidence was given at inquest that the ‘Care Plan system’ was a Hackney wide initiative implemented in August 2014 by CHUHSE in collaboration with GP practices. The scheme was still in its infancy. The intention was to ensure that the London Ambulance Service and Out of Hours Services would have full access to the patient records of the most vulnerable upon agreement of the patient. Questions were also raised about how the care plan would be kept up to date, and whether the London Ambulance Service would have computerised access to records. Doctors attending Out of Hours operate in a medical vacuum, acting on findings in that moment without access to previous medical history, blood and blood pressure test results. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Out of Hours access to previous medical history and clinical test results

    Wider context from the report

    “(4) Evidence was given at inquest that the ‘Care Plan system’ was a Hackney wide initiative implemented in August 2014 by CHUHSE in collaboration with GP practices. The scheme was still in its infancy. The intention was to ensure that the London Ambulance Service and Out of Hours Services would have full access to the patient records of the most vulnerable upon agreement of the patient. Questions were also raised about how the care plan would be kept up to date, and whether the London Ambulance Service would have computerised access to records. Doctors attending Out of Hours operate in a medical vacuum, acting on findings in that moment without access to previous medical history, blood and blood pressure test results. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of computerised record access for the London Ambulance Service

    Wider context from the report

    “(4) Evidence was given at inquest that the ‘Care Plan system’ was a Hackney wide initiative implemented in August 2014 by CHUHSE in collaboration with GP practices. The scheme was still in its infancy. The intention was to ensure that the London Ambulance Service and Out of Hours Services would have full access to the patient records of the most vulnerable upon agreement of the patient. Questions were also raised about how the care plan would be kept up to date, and whether the London Ambulance Service would have computerised access to records. Doctors attending Out of Hours operate in a medical vacuum, acting on findings in that moment without access to previous medical history, blood and blood pressure test results. ”
    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

Data last updated 7 September 2026