The Roehampton Surgery

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First report 26 Apr 2023•Latest report 26 Apr 2023

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 Roehampton Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner West London

    AI-generated summary

    Mrs Elsie Leaver · 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

    Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

    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 Roehampton Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure by SGH doctors to take a reasonable psychiatric history during clerking

    Wider context from the report

    “2. That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death. ”
    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 Roehampton Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal psychiatric liaison cover at QMH

    Wider context from the report

    “4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH, despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years. ”
    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 Roehampton Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Omission of pertinent psychiatric history from GP summaries

    Wider context from the report

    “1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver’s depression and specifically her suicidality. ”
    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 Roehampton Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient SGH doctor training on HIE information and access

    Wider context from the report

    “3. That doctors at SGH need training on the information available on HIE and how to access it. ”
    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 Roehampton Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice

    Wider context from the report

    “5. That the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH, when they are physically frail, given that QMH is a rehabilitation unit. ”
    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