Recipient

The Brooke Surgery

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First report 15 May 2026•Latest report 15 May 2026

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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
1

Across all linked responses

Stated actions
7

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
7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Manchester South

    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.

    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 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

    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
    Page 2 · response
    Published 14 August 2026

    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

    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
    Page 2 · response
    Published 14 August 2026

    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

    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
    Page 2 · response
    Published 14 August 2026

    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

    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
    Page 2 · response
    Published 14 August 2026

    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

    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
    Page 1 · response
    Published 14 August 2026

    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
71%14%14%
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