The Pembroke Medical Practice

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First report 27 Jan 2025•Latest report 27 Jan 2025

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

  1. Devon, Plymouth and Torbay

    AI-generated summary

    William Antony Northcott · 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

    William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.

    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 Pembroke Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to achieve clear communication of key information within community mental health teams

    Wider context from the report

    “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been. I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care. ”
    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 Pembroke Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely detect Clozapine-associated cardiomyopathies

    Wider context from the report

    “The risk of myocarditis is reasonably well explained in Devon Partnership NHS Trust's policy documentation, but there is less of a focus on cardiomyopathies which would include left ventricular hypertrophy. I understand that the Trust's guidance is based on national guidance. Annual ECGs are required for patients prescribed Clozapine and questions about cardiac function will now be asked at monthly Clozapine clinics. However, I understand that ECGs are not a diagnostic tool used to assist in the diagnosis of cardiomyopathies such as left ventricular hypertrophy and that left ventricular hypertrophy can be asymptomatic. I also understand that an echocardiogram may be able to identify such cardiomyopathies, but that this is not currently required on initiation of Clozapine or routinely at any other time whilst a patient is taking Clozapine. I am concerned that these cardiomyopathies could therefore go undetected in patients prescribed Clozapine and leave them at unknown increased risk of fatal cardiac arrhythmias, as occurred in William's case. Given that the Trust's guidance is based on national guidance I am concerned this may be a national issue. ”
    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 Pembroke Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices

    Wider context from the report

    “Currently around 60% of the cohort of patients prescribed Clozapine who are under the care of Devon Partnership Trust have access to these clinics. The other 40% will attend their GP surgery for their monthly Clozapine phlebotomy service. The phlebotomy service provided at a GP practice is usually an appointment with a non-qualified member of staff, who will not have been specifically trained in the side effects of Clozapine. I am therefore concerned that the level of care provided to patients attending Clozapine clinics on a monthly basis, is likely to be superior to the care provided to those patients who attend their GP practice. In particular, I am concerned that any discussion and repetition of information surrounding red flags and side effects associated with Clozapine, and advice about when to seek medical attention, will be significantly more limited for those patients attending their GP practice than for those attending the monthly Clozapine clinics. I am also concerned that this limitation is likely to extend further than the 40% of patients in receipt of Clozapine under the care of Devon Partnership NHS Trust and that this may be a national issue. ”
    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 Pembroke Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to achieve clear communication of key information with other agencies involved in patient care

    Wider context from the report

    “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been. I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care. ”
    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