Recipient

The Practice

First report 1 Nov 2013•Latest report 31 Dec 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

31 Dec2015
Norfolk
Concerns raised3
1. Lack of a method for recognising calls requiring immediate escalation
2. Lack of a domestic-abuse-specific questionnaire
3. Failure of the domestic abuse response flowchart to provide clear abuse-specific risk assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

MARGARET CAROLE ANN PEGNALL · 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

On 18 May 2015, Margaret Carole Ann Pegnall stepped into the path of a train at Stracey Arms, Norwich, and died from her injuries. Concerns included that the GP surgery’s domestic abuse response flowchart was vague, lacked a domestic abuse-specific questionnaire, and provided no method for staff to recognise when a patient’s call required immediate escalation.

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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of a method for recognising calls requiring immediate escalation
Wider context from the report
“(4) There was no method available to members of staff to recognise when a patient’s call should be escalated and dealt with immediately. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of a domestic-abuse-specific questionnaire
Wider context from the report
“(3) There is no Questionnaire specific to Domestic Abuse to assist in recognising signs of abuse and standardising the Surgery’s GPs’ response to concerns raised. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure of the domestic abuse response flowchart to provide clear abuse-specific risk assessment
Wider context from the report
“(2) The Flowchart for Responding to Domestic Abuse is vague and uses an Assessment of Risk pertaining to depression and not to the risk of abuse ”
Open source report
28 Nov2013
Milton Keynes
Concerns raised3
1. Unavailability of a pulse oximeter in the GP surgery
2. Lack of an effective communication system between GP surgeries and district nurses
3. Failure to provide the GP surgery with access to transferred patient records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Doris Phoebe Miller · 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

The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.

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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of a pulse oximeter in the GP surgery
Wider context from the report
“(3) During the inquest hearing it became apparent that the surgery at Broughton Gate did not have access to a pulse oximeter to measure Mrs Miller’s oxygenation. This is a relatively inexpensive item and should perhaps be available in every doctor’s surgery throughout the country. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of an effective communication system between GP surgeries and district nurses
Wider context from the report
“(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses. Again this gives rise to a concern that lives may be at risk. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide the GP surgery with access to transferred patient records
Wider context from the report
“(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery, following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records. Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk. ”
Open source report
1 Nov2013
East London
Concerns raised3
1. Inappropriate reliance on patients to communicate key clinical information to methadone prescribers
2. Lack of a procedure or policy ensuring clear communication between general practitioners and secondary care methadone providers
3. Failure to ensure methadone prescribers are fully informed of patients’ diagnosis, medication and treatment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Joanne Manning · 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

Joanne Manning had a history of poly-substance abuse and methadone treatment, developed asthma and increasing breathlessness, and died from respiratory failure. The inquest conclusion attributed the respiratory failure to the combination of her respiratory disease, methadone, mirtazapine, cocaine and morphine. Concerns included a failure to provide the methadone-prescribing psychiatrist with information about her diagnosis and treatment, and the absence of a procedure ensuring clear communication between general practice and secondary care methadone providers.

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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate reliance on patients to communicate key clinical information to methadone prescribers
Wider context from the report
“(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of a procedure or policy ensuring clear communication between general practitioners and secondary care methadone providers
Wider context from the report
“(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
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 Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure methadone prescribers are fully informed of patients’ diagnosis, medication and treatment
Wider context from the report
“(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised3

Lack of a method for recognising calls requiring immediate escalation

Lack of a domestic-abuse-specific questionnaire

Failure of the domestic abuse response flowchart to provide clear abuse-specific risk assessment

Concerns raised3

Unavailability of a pulse oximeter in the GP surgery

Lack of an effective communication system between GP surgeries and district nurses

Failure to provide the GP surgery with access to transferred patient records

Concerns raised3

Inappropriate reliance on patients to communicate key clinical information to methadone prescribers

Lack of a procedure or policy ensuring clear communication between general practitioners and secondary care methadone providers

Failure to ensure methadone prescribers are fully informed of patients’ diagnosis, medication and treatment