Recipient

The Waterfield Practice

First report 28 Nov 2018•Latest report 28 Nov 2018

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

28 Nov2018
Berkshire
Concerns raised6
1. Lack of knowledge of the signs and symptoms of venous thromboembolism
2. Insufficient medical registrar cover at night
3. Deficient GP record-keeping practices
1. Insufficient clinical knowledge of unexpected deaths and related clinical management
2. Failure of the GP practice system to investigate unexpected deaths
3. Deficient GP record keeping
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

Michelle Roach · 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

Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.

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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of knowledge of the signs and symptoms of venous thromboembolism
Wider context from the report
“(1) I believe ████████ should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism. ”
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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Insufficient medical registrar cover at night
Wider context from the report
“(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust. ”
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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Deficient GP record-keeping practices
Wider context from the report
“(2) I believe ████████ should review her record-keeping practices. ”
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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Insufficient clinical knowledge of unexpected deaths and related clinical management
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure of the GP practice system to investigate unexpected deaths
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
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 Waterfield Practice; that does not assign responsibility.
PFD Monitor interpretation
Deficient GP record keeping
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
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 raised6

Lack of knowledge of the signs and symptoms of venous thromboembolism

Insufficient medical registrar cover at night

Deficient GP record-keeping practices

Insufficient clinical knowledge of unexpected deaths and related clinical management

Failure of the GP practice system to investigate unexpected deaths

Deficient GP record keeping