Recipient

St Chads Medical Practice

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First report 14 Feb 2019•Latest report 14 Feb 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
6

Described in responses

Reports over time

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
6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Manchester North

    AI-generated summary

    John Andrew Mellor · 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

    John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.

    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 Chads Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring

    Wider context from the report

    “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility. The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe. It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider. ”
    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 Chads Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure required blood tests for individuals under specialist secondary care for renal failure

    Wider context from the report

    “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility. The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe. It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider. ”
    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 Chads Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate referral responses, referral updates and community test requests directly to primary care

    Wider context from the report

    “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility. The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe. It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider. ”
    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

    Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.

    Verbatim wording from the response

    “The Practice should have alerted the CCG to the fact that they were being asked to arrange monitoring of a red status medication so that the CCG could liaise with secondary care to arrange a Medication Management. We wrote to the CCG on 11 February 2019 to notify them of this significant event and the upcoming Coroner’s Inquest. Please find a copy of that letter enclosed with this response.”

    Source location

    2019-0053-Responses
    Page 12 · response
    Published 2 June 2019

    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

    The Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.

    Verbatim wording from the response

    “During a telephone call with ████████ at the CCG on 29 March 2019, the Practice was informed that we should not agree to the monitoring of red category medications and should notify the CCG urgently if asked to do so. The CCG are liaising directly with the Trust and also with Medications Management regarding this issue. At the request of the Trust we have not written to the Trust and the CCG are liaising with them directly in relation to the issues identified by the Practice and by the CCG.”

    Source location

    2019-0053-Responses
    Page 13 · response
    Published 2 June 2019

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
50%50%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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