Rookery Medical Centre

Health and care · Healthcare site

Pin Request correction

First report 29 Jun 2018•Latest report 29 Jun 2018

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

  1. Suffolk

    AI-generated summary

    DAPHNE JOAN PENN · 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

    Daphne Joan Penn was transferred to Newmarket Community Hospital for rehabilitation and later died after readmission to West Suffolk Hospital, following deterioration. The inquest recorded pneumonia as the cause of death and identified concerns about an inadvertently rapid reduction in her long-term steroid therapy, delays in communicating family concerns, and a prescribing error that caused an additional reduction in the steroid dose.

    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 Rookery Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately transcribe intended steroid doses when rewriting drug charts

    Wider context from the report

    “The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart. ”
    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 Rookery Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in transmitting patient-condition concerns to relevant medical staff

    Wider context from the report

    “The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart. ”
    Open source report
Back to top

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