15 May 2026 Edith May Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Poor quality of District Nursing team documentation View source Insufficient managerial oversight of complex District Nursing cases View source Failure of District Nurses to promptly escalate deteriorating patients View source District Nursing gateway triage failing to identify or proactively manage deteriorating patients View source Lack of an effective GP practice system to promptly triage 111 referrals and family-provided information View source See 2 more concerns
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. 5
Action
Implement an External Clinical Communication and Triage Protocol covering receipt, prioritisation, escalation and documentation of external clinical communications.
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Action
Review the effectiveness of the Protocol in September 2026.
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Action
Include NHS 111 referral management in periodic governance and audit processes.
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Action
Present the Protocol to staff and make it available on the internal knowledge platform for review and future reference.
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Action
Introduce a revised on-call structure with a duty clinician and second on-call clinician supporting each clinical session.
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AI-generated summary
Edith May Jones · 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
Edith May Jones had limited mobility and underlying health conditions, including heart failure, and developed a deteriorating sacral pressure ulcer. She was admitted to hospital with an infected stage 4 pressure ulcer, did not improve despite intravenous antibiotics, and died on 17 October 2025; the stated cause was heart failure exacerbated by the infected ulcer. Concerns included poor District Nursing documentation, limited managerial oversight, delayed escalation, shortcomings in the gateway referral triage process, and ineffective GP triage of referrals and family information.
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× 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 Brooke Surgery; that does not assign responsibility.
PFD Monitor interpretation Poor quality of District Nursing team documentation
Wider context from the report “1. The quality of the District Nursing team documentation was poor . Consequently, it was difficult to understand the steps taken and the rationale for actions ;
” 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 Brooke Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient managerial oversight of complex District Nursing cases
Wider context from the report “2. There was little evidence of oversight by District Nursing Team managers of how complex cases such as Mrs Jones were being managed ;
” 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 Brooke Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of District Nurses to promptly escalate deteriorating patients
Wider context from the report “3. There was no prompt escalation of her case by the District Nurses when the situation deteriorated ;
” 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 Brooke Surgery; that does not assign responsibility.
PFD Monitor interpretation District Nursing gateway triage failing to identify or proactively manage deteriorating patients
Wider context from the report “4. The District Nursing gateway referral system had a triage process that did not identify or manage proactively her deteriorating 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 The Brooke Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective GP practice system to promptly triage 111 referrals and family-provided information
Wider context from the report “5. The GP practice did not have an effective system to promptly triage referrals from the 111 service or information provided by a patients family .
” 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 Implement an External Clinical Communication and Triage Protocol covering receipt, prioritisation, escalation and documentation of external clinical communications.
Verbatim wording from the response “Following this, the Practice implemented a new External Clinical Communication and Triage Protocol (‘the Protocol’), which sets out the Practice’s approach to the receipt, prioritisation, escalation and documentation of external clinical communications. The Protocol and its particulars were presented to staff at the clinical meeting on 18 June 2026. It has also been made available on the Practice’s internal knowledge platform, TeamNet, for staff review and future reference.” Source location Response from The Brooke 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 the effectiveness of the Protocol in September 2026.
Verbatim wording from the response “The Practice intends to review the effectiveness of the Protocol in September 2026, and the management of NHS 111 referrals will form part of the Practice’s periodic governance and audit processes.” Source location Response from The Brooke 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 Include NHS 111 referral management in periodic governance and audit processes.
Verbatim wording from the response “The Practice intends to review the effectiveness of the Protocol in September 2026, and the management of NHS 111 referrals will form part of the Practice’s periodic governance and audit processes.” Source location Response from The Brooke 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 Present the Protocol to staff and make it available on the internal knowledge platform for review and future reference.
Verbatim wording from the response “Following this, the Practice implemented a new External Clinical Communication and Triage Protocol (‘the Protocol’), which sets out the Practice’s approach to the receipt, prioritisation, escalation and documentation of external clinical communications. The Protocol and its particulars were presented to staff at the clinical meeting on 18 June 2026. It has also been made available on the Practice’s internal knowledge platform, TeamNet, for staff review and future reference.” Source location Response from The Brooke 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 Introduce a revised on-call structure with a duty clinician and second on-call clinician supporting each clinical session.
Verbatim wording from the response “In September 2025, the Practice introduced a revised on-call structure whereby each clinical session is supported by both a duty clinician and a second on-call clinician. This change, introduced as part of wider service development, has strengthened resilience within the clinical triage system, provided additional support for the escalation of urgent concerns and reduced reliance on a single clinician during periods of high demand.” Source location Response from The Brooke Surgery
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations