Three Chequers Medical Practice

Health and care · Healthcare site

Pin Request correction

First report 29 Jul 2016•Latest report 29 Jul 2016

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

  1. Addressed to Endless Street Doctors' Surgery, now represented here by Three Chequers Medical Practice.

    Wiltshire and Swindon

    AI-generated summary

    Miles Benedict Abel · 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 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.

    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 Three Chequers Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an audit trail for faxed referrals to the Community Mental Health Team

    Wider context from the report

    “(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
    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 Three Chequers Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals

    Wider context from the report

    “(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
    Open source report
Back to top

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