Richmond Medical Centre (Solihull)

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First report 24 Nov 2016•Latest report 24 Nov 2016

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

  1. Birmingham and Solihull

    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
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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