The Waterfield Practice

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First report 28 Nov 2018•Latest report 28 Nov 2018

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

  1. Berkshire

    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
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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