20 Nov 2018 Sarah Kiff · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Reluctance by male doctors to carry out internal examinations on female patients View source Inadequate processes for recording test results in electronic patient records View source Poor medical record keeping View source Failure by doctors to review clinical history before consultation View source Lack of continuity of care View source Failure to communicate explicit requirements between medical and nursing teams View source Inadequate processes for reviewing test results View source Failure by GPs to follow cancer referral guidance View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 8
Action
Conduct annual cancer-analysis audits, review each new cancer diagnosis for missed opportunities, and share learning through clinical-governance meetings.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Review and disseminate new NICE guidance monthly to clinicians, updating relevant practice protocols when necessary.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Use a written high-vaginal-swab protocol requiring cervical-speculum visualization, documentation of findings, and GP review of abnormalities.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Provide protected time between consultations by changing schedules to allow clinicians to review patients’ past and current clinical problems.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Use updated diagnostic-result processes to action results on receipt, arrange follow-up for results requiring it, notify patients appropriately, and audit actions in clinical records.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Refresh doctors’ knowledge of GMC record-keeping guidance and improve the detail of clinical documentation.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source
Action
Enable some male GPs to undertake further training in female pelvic examination techniques.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2018. View source
Action
Use a written internal-referral policy directing patients to a more appropriate clinician for examinations or procedures.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2018. View source See 5 more actions
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AI-generated summary
Sarah Kiff · 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
Sarah Kiff experienced repeated consultations for vaginal discharge, urinary symptoms, heavy menstruation and lower abdominal pain before cervical cancer was diagnosed after an urgent referral in July 2013. The cancer had metastasised to the liver and, after treatment and subsequent decline, she suffered a cardiac arrest and died at Fairfield General Hospital on 14 October 2015. The report identified concerns about failure to follow cancer referral guidance, inadequate examination and history-taking, poor record-keeping and communication, lack of continuity of care, reluctance to perform internal examinations, and inadequate processes for reviewing test results.
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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Reluctance by male doctors to carry out internal examinations on female patients
Wider context from the report “4. During the course of the evidence it became apparent that male doctors were reluctant to carry out internal examinations on female patients as they felt it more appropriate for their female colleagues to do them. Reluctance was not related to patient preference (in this case the patient was not offered any such examination) . Moreover they felt that female doctors were, skill wise, more able.
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Inadequate processes for recording test results in electronic patient records
Wider context from the report “5. The processes and procedures in place for reviewing test results and ensuring that they appear within the patient's electronic records appears to be inadequate .
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Poor medical record keeping
Wider context from the report “2. Medical record keeping and communication between the medical and nursing teams was poor . The doctor's were not explicit about what they required the nurse to do in terms of P.V. examination and made assumption that the nurse/s knew what the doctors expected of them.
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure by doctors to review clinical history before consultation
Wider context from the report “3. There was lack of continuity of care and a failure by doctors to fully appraise themselves of the clinical history ahead of consultation . The care provided to Ms Kiff was, on occasions, perfunctory.
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care
Wider context from the report “3. There was lack of continuity of care and a failure by doctors to fully appraise themselves of the clinical history ahead of consultation. The care provided to Ms Kiff was, on occasions, perfunctory.
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate explicit requirements between medical and nursing teams
Wider context from the report “2. Medical record keeping and communication between the medical and nursing teams was poor . The doctor's were not explicit about what they required the nurse to do in terms of P.V. examination and made assumption that the nurse/s knew what the doctors expected of them .
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Inadequate processes for reviewing test results
Wider context from the report “5. The processes and procedures in place for reviewing test results and ensuring that they appear within the patient's electronic records appears to be inadequate .
” 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 Stonefield Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure by GPs to follow cancer referral guidance
Wider context from the report “1. GPs at the Practice did not follow the NICE 2005 cancer referral guidance . This puts patients at risk.
” Open source report
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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 Conduct annual cancer-analysis audits, review each new cancer diagnosis for missed opportunities, and share learning through clinical-governance meetings.
Verbatim wording from the response “The practice has produced an annual audit report around new cancer diagnoses for several years, with the records of each patient being reviewed by a clinician looking to see if there were any lost opportunities to diagnose the condition earlier and to ensure NICE guidance was correctly followed. These Cancer Analysis Audits are discussed at the clinical governance meetings and any learning points are shared within the practice team.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Review and disseminate new NICE guidance monthly to clinicians, updating relevant practice protocols when necessary.
Verbatim wording from the response “In July 2015 new cancer guidance NG12 was produced by NICE. These were discussed within the practice meeting, with each partner being provided with copies of the Macmillan summary guidance and copies of the BMJ flow chart which are laminated and on the wall of each consulting room. The deputy Practice Manager now ensures that all new NICE guidance is shared with clinicians monthly via email and the lead clinician in the relevant area is responsible for ensuring that any new recommendations are shared, and protocols altered where necessary. This process has now been in place for over 2 years.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Use a written high-vaginal-swab protocol requiring cervical-speculum visualization, documentation of findings, and GP review of abnormalities.
Verbatim wording from the response “At that time, it was agreed that any female patient needing assessment who had presented to a male doctor that had concerns about their skills in examination, would be handed over to one of the female GPs. Similarly, where male patients felt uncomfortable about having pelvic examinations performed by a female GP, then the same onward referral protocol would be followed. This agreement has been in place since October 2013. More recent discussions have also concentrated on the methodology for taking high vaginal swabs following your comments, and it has been reconfirmed that these are all done using cervical speculums, so that the cervix is visualized during the test. Any abnormality found by the nursing staff will be highlighted to one of the GPs. The practice now has an agreed protocol for performing HVS.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 protected time between consultations by changing schedules to allow clinicians to review patients’ past and current clinical problems.
Verbatim wording from the response “Due to increasing complexity of many patients, the practice has altered consulting schedules so that blocks between every few patients allow the doctor time to ensure they are up to date with past and current clinical problems for each patient. The blocks result in the standard appointment time of 12 minutes instead of 10 minutes. I have already alluded in sections 1 & 2, to processes now in place to ensure that clinical records are more accurate and that the relevant examinations are performed.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Use updated diagnostic-result processes to action results on receipt, arrange follow-up for results requiring it, notify patients appropriately, and audit actions in clinical records.
Verbatim wording from the response “The practice has robust processes in place to ensure all diagnostics are actioned on the same day of receipt and where there is an abnormal result these are followed up with the patient. The GP can readily look in the clinical records to review why the test was performed. On most occasions the GP who orders the test will be reviewing the results, but this is not always possible due to patterns of working. In addition, some providers return results to the registered GP rather than the one requesting the test.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Refresh doctors’ knowledge of GMC record-keeping guidance and improve the detail of clinical documentation.
Verbatim wording from the response “Review of the medical records for Miss Kiff has highlighted that the record keeping was not adequate, and this has allowed the clinical staff to review the method for clinical note recording, ensuring in future that more detailed records are kept. Each clinician has now reviewed the GMC guidance on record keeping in Good Medical Practice (2013) at paragraphs 19-21.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Enable some male GPs to undertake further training in female pelvic examination techniques.
Verbatim wording from the response “As an additional learning action, the practice has been able to get the support of ████████ a Gynaecology Oncologist at Pennine Acute Trust, who has agreed to provide a training session for the clinicians at Stonefield Street Surgery in early 2018 around the recognition of Gynaecological malignancies and management of female problems. Some of the male partners are also looking to attend local Gynaecology clinics to help improve their competency in vaginal examinations.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Use a written internal-referral policy directing patients to a more appropriate clinician for examinations or procedures.
Verbatim wording from the response “At that time, it was agreed that any female patient needing assessment who had presented to a male doctor that had concerns about their skills in examination, would be handed over to one of the female GPs. Similarly, where male patients felt uncomfortable about having pelvic examinations performed by a female GP, then the same onward referral protocol would be followed. This agreement has been in place since October 2013. More recent discussions have also concentrated on the methodology for taking high vaginal swabs following your comments, and it has been reconfirmed that these are all done using cervical speculums, so that the cervix is visualized during the test. Any abnormality found by the nursing staff will be highlighted to one of the GPs. The practice now has an agreed protocol for performing HVS.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Test results were clearly visible in the electronic record, contrary to the concern that results were not appearing within patient records.
Verbatim wording from the response “All test results relating to Miss Sarah Kiff are clearly visible within the patient electronic record. The EMIS computer system records date test requested date received, date of review and filing as well as any practice notes made by the doctor. The report comments on the Ultrasound Scan result for Miss Kiff, but the records clearly show that the report was received on the 25th February, seen and noted to be normal and filed in the patient record, so this was unfortunately not available for her appointment with Dr Younis on 22nd February 2013. This is all auditable within the clinical system.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
Open published response
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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 Existing diagnostic-result processes ensure tests are actioned on receipt, abnormal results are followed up, and actions are auditable.
Verbatim wording from the response “The practice has robust processes in place to ensure all diagnostics are actioned on the same day of receipt and where there is an abnormal result these are followed up with the patient. The GP can readily look in the clinical records to review why the test was performed. On most occasions the GP who orders the test will be reviewing the results, but this is not always possible due to patterns of working. In addition, some providers return results to the registered GP rather than the one requesting the test.” Source location 2017-0407-Response-by-Stonefield-Street-Surgery
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations