Recipient

Three Chequers Medical Practice

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First report 29 Jul 2016•Latest report 29 Jul 2016

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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
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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

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
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