Recipient

Recipient name withheld

First report 20 May 2015•Latest report 20 May 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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

20 May2015
Inner North London
Concerns raised7
1. Reliance on asthma pump use as a significant diagnostic tool
2. Failure to ensure identified vulnerable patients possess care plans
3. Failure to raise care-plan provision during subsequent patient contacts
1. Failure to ask about the reason for asthma pump use
2. Unclear arrangements for keeping care plans up to date
3. Lack of Out of Hours access to previous medical history and clinical test results
4. Unavailability of computerised record access for the London Ambulance Service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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 raised7

Reliance on asthma pump use as a significant diagnostic tool

Failure to ensure identified vulnerable patients possess care plans

Failure to raise care-plan provision during subsequent patient contacts

Failure to ask about the reason for asthma pump use

Unclear arrangements for keeping care plans up to date

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

Unavailability of computerised record access for the London Ambulance Service