The Beaufort Road SurgeryIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 1 Aug 2023•Latest report 1 Aug 2023

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 The Beaufort Road Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Practice Manager, The Beaufort Road Surgery.

    Dorset

    AI-generated summary

    Edward England Rhodes · 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

    Edward England Rhodes, who had a history of alcohol misuse, relapsed after a period of abstinence and was found unresponsive on 17 November 2022. Toxicology revealed methadone at a level consistent with severe, possibly fatal toxicity, and the inquest recorded a drug-related death. Concerns included a possible breakdown or misunderstanding between Mr Rhodes and his GP about the steps required for a mental health referral, and the absence of clear written confirmation of respective responsibilities.

    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 The Beaufort Road Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Breakdown in communication about the steps and responsibilities for Mental Health referral

    Wider context from the report

    “2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict. iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient. iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient. ”
    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 The Beaufort Road Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to send a letter confirming the respective responsibilities of the doctor and patient

    Wider context from the report

    “2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict. iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient. iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient. ”
    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 The Beaufort Road Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of an automatic Mental Health referral pathway after 90 days of sobriety

    Wider context from the report

    “2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict. iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient. iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient. ”
    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 The Beaufort Road Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on verbal discussions during consultations with patients with addiction

    Wider context from the report

    “2. I have concerns with regard to the following: i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral. ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict. iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient. iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient. ”
    Open source report
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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