Recipient

Ringmead Medical Group

First report 6 Feb 2024•Latest report 6 Feb 2024

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: 100%
Concerns addressed: 2
Stated actions: 3

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.

100%published responses found

3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Ringmead Medical Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

6 Feb2024
Berkshire
Concerns raised2
1. Failure to record and highlight patients' current or former smoking status in an immediately accessible manner
2. Failure to routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Reinforced clinical guidance to consider chest X-rays for persistent respiratory symptoms, repeated antibiotics and smoking history.
  Stated completed
2. Action
  Circulated the chest X-ray assessment information to locum GPs.
  Stated completed
3. Action
  Clarified how clinicians should check and document smoking status using the patient care history during consultations.
  Stated completed
Respondent positions 2
1. Position
  A written practice guideline for chest X-ray requests was difficult because the decision requires individual clinical assessment.
  Unable to act
1. Position
  Immediate visibility of smoking status when opening patient notes was not feasible because of IT issues affecting more than 42,000 patients.
  Unable to act
AI-generated summary

Paula Elizabeth ELSLEY · 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

Paula Elizabeth ELSLEY was found unresponsive at home on 28 March 2022 and declared deceased. The inquest concluded that she was suffering from undiagnosed lung cancer with a metastatic brain tumour, which led to an abscess that caused her death. Concerns included smoking status not being readily accessible in GP records and NICE guidance on chest X-ray referral thresholds not being routinely considered or formally embedded in practice.

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 Ringmead Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to record and highlight patients' current or former smoking status in an immediately accessible manner
Wider context from the report
“1. Smoking status During the inquest I heard evidence that a patient's smoking status (current or former) was not routinely recorded by the GP practice in a manner that was immediately accessible when reviewing the medical records. I heard that it may be necessary to search through consultation notes and other records to discover this information and GPs do not necessarily have time to do so. A patient's current or former smoking status is relevant information for a GP considering whether a chest x-ray ought to be considered in line with NICE guideline entitled 'Suspected cancer: recognition and referral' (NG12). The GPs who gave evidence agreed that it would be helpful if this information was flagged and the GP practice has indicated that it intends to introduce such a system. However this is not yet in place and I am concerned that the risk of this information not being highlighted remains a current risk. ”
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 Ringmead Medical Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral
Wider context from the report
“2. Thresholds for referral for a chest xray Based on evidence heard at inquest I am concerned that at the time of Paula's death (March 2022) the same NICE guideline was not being routinely considered by GPs. I was very pleased to hear that the practice subsequently introduced their own internal tool for complying if the threshold for a chest x-ray had been reached and that this has been discussed at GP and partner meetings. However some 22 months have now elapsed since Paula's death and no formal policy has been prepared. I remain concerned that the risk of the guideline not being considered remains whilst the change is procedure is informal, especially when it needs to be disseminated to new or locum GPs and other healthcare professionals such as nurses, paramedics and physician associates. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reinforced clinical guidance to consider chest X-rays for persistent respiratory symptoms, repeated antibiotics and smoking history.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulated the chest X-ray assessment information to locum GPs.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Clarified how clinicians should check and document smoking status using the patient care history during consultations.

Verbatim wording from the response
“Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page).”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A written practice guideline for chest X-ray requests was difficult because the decision requires individual clinical assessment.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Immediate visibility of smoking status when opening patient notes was not feasible because of IT issues affecting more than 42,000 patients.

Verbatim wording from the response
“Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page).”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response

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 raised2

Failure to record and highlight patients' current or former smoking status in an immediately accessible manner

Failure to routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 3

Respondent positions 2