Recipient

Richmond Medical Centre (Solihull)

First report 24 Nov 2016•Latest report 24 Nov 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 Richmond Medical Centre (Solihull) linked to the concerns in each report. Select any concern, action or position to view the source wording.

24 Nov2016
Birmingham and Solihull
Concerns raised6
1. Failure to prescribe the appropriate antibiotics for specific clinical situations
2. Failure to provide GP clinical assessment for patients with deteriorating conditions and complex needs
3. Failure to maintain accurate records of patient contacts and clinical decisions
1. Failure of the home visit policy to address complex chronic conditions in care or residential facilities
2. Failure to distinguish clinical assessment tasks from true administration tasks
3. Failure to clearly request and document home visits
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

Timothy Simon Jones · 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

Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure to prescribe the appropriate antibiotics for specific clinical situations
Wider context from the report
“5. The deceased was diagnosed with aspiration pneumonia when he was admitted to hospital. He was at high risk of aspiration pneumonia. I heard evidence that the best antibiotics for aspiration pneumonia are co-amoxiclav. The deceased was not prescribed these in the community he was given amoxicillin instead. Consideration needs to be given whether guidelines should be produced to clarify which antibiotics are required in specific situations. ”
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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure to provide GP clinical assessment for patients with deteriorating conditions and complex needs
Wider context from the report
“3. There was no clinical assessment of the deceased by a GP after the 25 May 2016 despite his deteriorating condition and complex needs. ”
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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain accurate records of patient contacts and clinical decisions
Wider context from the report
“1. I have concerns about record keeping at the practice. The residential home records recorded that the GP had visited the patient on 25 May 2016, however the GP could not find a record of that visit in the electronic notes. It is vital the accurate records are kept of contact with patients and clinical decisions made. ”
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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure of the home visit policy to address complex chronic conditions in care or residential facilities
Wider context from the report
“4. The GP’s policy for home visits (copy attached) did not contain any reference to those with complex chronic conditions who were residents in care or residential facilities. The policy actively seeks to avoid home visits which may have influenced decision making in this case. ”
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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure to distinguish clinical assessment tasks from true administration tasks
Wider context from the report
“2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”
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 Richmond Medical Centre (Solihull); that does not assign responsibility.
PFD Monitor interpretation
Failure to clearly request and document home visits
Wider context from the report
“2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”
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 raised6

Failure to prescribe the appropriate antibiotics for specific clinical situations

Failure to provide GP clinical assessment for patients with deteriorating conditions and complex needs

Failure to maintain accurate records of patient contacts and clinical decisions

Failure of the home visit policy to address complex chronic conditions in care or residential facilities

Failure to distinguish clinical assessment tasks from true administration tasks

Failure to clearly request and document home visits