Townhead Surgery

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First report 25 Apr 2025•Latest report 25 Apr 2025

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
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
4

Described in responses

Concerns and recipient responses

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

  1. North Yorkshire and York

    AI-generated summary

    Richard James MOSS · 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

    Richard James Moss attended his general practitioner with intermittent chest discomfort on 15 March 2024 and was later found deceased on 29 May 2024; the recorded cause of death was myocardial infarction due to coronary artery thrombosis. His intended referral to the Rapid Access Chest Pain Clinic had not been actioned, and the practice referral system only alerted colleagues when a practitioner manually selected the alert option.

    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 Townhead Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of completed referral documents to automatically generate alerts for colleagues to action referrals

    Wider context from the report

    “When a referral document is completed by a medical practitioner at this practice, an alert to colleagues to action the referral will only be sent if the practitioner manually selects the option to do so rather than every referral document completion automatically generating an alert. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the referral process through a significant event meeting to identify failures and prevent recurrence.

    Verbatim wording from the response

    “We held a significant event meeting 23.07.24 for the GPs and Practice Manager. The purpose of the meeting was to determine whether anything had gone wrong with our referral process, and if so, could we prevent a recurrence. We determined that the Rapid Access Chest Pain referral form sits within an IT software system called “GP Assist.” GP Assist is used by all local GP surgeries to generate referrals to secondary care. In this case “GP Assist” gives the referring GP the option to either 1) Open the document and send a task (to secretaries) at the same time, or 2) Open the document only (no task generated unless done so manually). Dr Kerry used option 2) and once the referral form had been completed there was no automatic reminder to alert the secretarial team.”

    Source location

    Response from Townhead Surgery
    Page 1 · response
    Published 19 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Request removal of the GP Assist option that allows referral forms to be sent without a secretarial alert.

    Verbatim wording from the response

    “Following the significant event meeting we approached GP Assist to ask that they remove option 2) from the clinical system. We felt this would be safer, as it would force”

    Source location

    Response from Townhead Surgery
    Page 1 · response
    Published 19 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Escalate the referral safety concern to the Integrated Care Board and raise awareness among other practices.

    Verbatim wording from the response

    “We have raised this matter at a meeting held between the practice and representatives from NHS West Yorkshire Integrated Care Board on 06 June 2025. The outcome from this meeting is that we are escalating the matter to ICB level in the hope that other practices are made aware of the potential problem, but also so that the referral process can be made safer by the IT team. I enclose a copy of the letter that I have sent the ICB.”

    Source location

    Response from Townhead Surgery
    Page 2 · response
    Published 19 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a fortnightly internal report to identify unsent Rapid Access Chest Pain referrals.

    Verbatim wording from the response

    “We have had to develop our own internal safety system. This consists of a reporting system that searches all our patients for any unsent Rapid Access Chest Pain Referral. We run the report every two weeks. We have been using this since last year. So far, we have not detected any other missed referrals.”

    Source location

    Response from Townhead Surgery
    Page 2 · response
    Published 19 May 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for the referral form and process lies with Airedale Hospital’s cardiology and IT departments, not the GP surgery.

    Verbatim wording from the response

    “It is important to note that the Rapid Access Chest Pain referral form and the clinical IT system in which it sits are not owned or controlled by the GP surgery. The cardiology department at Airedale hospital, together with the IT department are responsible for the form content and referral process.”

    Source location

    Response from Townhead Surgery
    Page 1 · response
    Published 19 May 2025

    Open published response
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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