St Andrews Surgery

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First report 9 Mar 2024•Latest report 9 Mar 2024

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
Published responses: 100%
Concerns addressed: 2
Stated actions: 4

Concerns and recipient responses

Statements from St Andrews Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Mar2024
East Riding and Hull
Concerns raised4
1. Insufficient inquiry into the parameters of care provided by private domiciliary carers
2. Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
3. Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
1. Failure to make post-discharge referrals for patients needing district nursing care
Actions described in response 3
1. Action
  Recruit a Data Quality and IT Officer to oversee data-quality audits and provide training where applicable.
2. Action
  Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.
3. Action
  Provide staff training and updates on accurate, detailed patient-record documentation and good record-keeping.
AI-generated summary

Linda Heath · 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

Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.

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 St Andrews Surgery; that does not assign responsibility.
PFD Monitor interpretation
Insufficient inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report
“(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers. ”
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 St Andrews Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report
“(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. ”
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 St Andrews Surgery; that does not assign responsibility.
PFD Monitor interpretation
Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report
“(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition. ”
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 St Andrews Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report
“(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery. ”
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
Recruit a Data Quality and IT Officer to oversee data-quality audits and provide training where applicable.

Verbatim wording from the response
“2. Training: Additional training and updates have been provided to all staff regarding the importance of good record-keeping. This includes understanding the significance of accurate and detailed documentation in the patient record. We have recently recruited a Data Quality and IT Officer to oversee and ensure that data is of a high standard through audits and training where applicable.”

Source location
Response from GP Surgery
Page 1 · response
Published 14 May 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
Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.

Verbatim wording from the response
“To address concerns regarding the lack of referrals to the district nursing team and other issues raised, the following measures have been discussed with the practice team and implemented to prevent future occurrences:”

Source location
Response from GP Surgery
Page 1 · response
Published 14 May 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
Provide staff training and updates on accurate, detailed patient-record documentation and good record-keeping.

Verbatim wording from the response
“2. Training: Additional training and updates have been provided to all staff regarding the importance of good record-keeping. This includes understanding the significance of accurate and detailed documentation in the patient record. We have recently recruited a Data Quality and IT Officer to oversee and ensure that data is of a high standard through audits and training where applicable.”

Source location
Response from GP Surgery
Page 1 · response
Published 14 May 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 raised4

Insufficient inquiry into the parameters of care provided by private domiciliary carers

Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information

Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments

Failure to make post-discharge referrals for patients needing district nursing care

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

Actions described in response 3