Recipient

The Richmond ClinicIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 14 Jan 2022•Latest report 14 Jan 2022

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
2

Across all linked responses

Stated actions
2

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
2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Addressed to: Senior Partner, The Richmond Clinic.

    Gwent

    AI-generated summary

    Brian Wareham · 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

    Brian Wareham was diagnosed with oesophageal dysmotility, which worsened and prevented him from eating sufficiently to maintain his nutritional status; he died at St David’s Hospice on 2 November 2020. The report raised concerns about communication and collaboration between primary and secondary care, including uncertainty about his treatment approach and a breakdown in communication, trust and respect between clinicians.

    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 Richmond Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of communication and collaboration between primary and secondary care

    Wider context from the report

    “1. Communication and collaboration between primary and secondary care. Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet. In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative. Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge. When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care. The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians. ”
    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 Richmond Clinic; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to directly contact the responsible medical team to address significant concerns

    Wider context from the report

    “1. Communication and collaboration between primary and secondary care. Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet. In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative. Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge. When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care. The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians. ”
    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

    Explore primary–secondary care communication options, identify case-specific barriers, address them, and ensure clinical staff know the available routes.

    Verbatim wording from the response

    “As per section (6) – “Action should be taken”, I can confirm that this matter has been investigated within the practice. In addition, following a meeting between Dr ████████ and representatives of the Health Board on 2nd February 2022, we understand a further process is continuing within the Health Board, with which we are cooperating fully. As part of this process we have fully explored all current options and opportunities for communication between Primary and Secondary Care and have ensured that all clinical staff are aware of them. In particular we have explored specific obstacles to communication within this case and addressed them. We understand that there is an ongoing programme within the Health Board to further facilitate communication between primary and Secondary Care and we are engaging positively with that work.”

    Source location

    2022-0010-Response-from-The-Richmond-Clinic_Published
    Page 1 · response
    Published 20 January 2022

    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

    Continue cooperating with and positively engaging in the Health Board’s programme to facilitate primary–secondary care communication.

    Verbatim wording from the response

    “As per section (6) – “Action should be taken”, I can confirm that this matter has been investigated within the practice. In addition, following a meeting between Dr ████████ and representatives of the Health Board on 2nd February 2022, we understand a further process is continuing within the Health Board, with which we are cooperating fully. As part of this process we have fully explored all current options and opportunities for communication between Primary and Secondary Care and have ensured that all clinical staff are aware of them. In particular we have explored specific obstacles to communication within this case and addressed them. We understand that there is an ongoing programme within the Health Board to further facilitate communication between primary and Secondary Care and we are engaging positively with that work.”

    Source location

    2022-0010-Response-from-The-Richmond-Clinic_Published
    Page 1 · response
    Published 20 January 2022

    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
50%50%
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