Recipient

Wanstead Place Surgery

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First report 23 Mar 2017•Latest report 23 Mar 2017

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 Wanstead Place Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Grant Lincoln RICHARDS · 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

    Grant Richards died by suicide on 19 October 2016 after ejecting himself from a tenth-floor window and suffering catastrophic injuries. The report identified failures to act on an A&E request for chest-clinic follow-up, failures in contingency and audit systems, omissions in GP reporting, and failures to act on mental-health service fax communications. It noted that anxiety about possible lung cancer may have prolonged or exacerbated his depression leading to his suicide.

    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 Wanstead Place Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record relevant A&E attendance and discharge information in GP reports

    Wider context from the report

    “Mr Richards previous medical history included diagnoses of depression, and anxiety, for which he was treated at various times pharmacologically, by inpatient treatment in a secure hospital, by access to the Home Treatment Team and by community based mental health care. His history included self-harm and suicide attempt. His anxieties included financial worry, debt, unemployment and eviction. He attended A&E at Whipps Cross Hospital on 23rd July 2016 for treatment of pain in his right loin. Whilst there he was x-rayed to the chest, which revealed a “shadow” on the right side. The hospital advised Mr Richards and his sister who attended with him that this matter would be raised with the GP, and he was informed that the hospital recommended follow-up in the chest clinic. The discharge summary recorded “disch for GP F/Up – to check progress” and also specifically noted the clinician’s comments which included “please arrange F/U in the chest clinic”. A letter was given to the patient as well as emailed to the GP surgery. The initial GP evidential witness report to the Coroner, prepared for submission to the Inquest, made no mention of this event. I heard evidence that the usual surgery protocol was that a reviewing doctor would assess all emailed reports received into the surgery, and in a case like this would instruct the surgery receptionist to contact the patient to arrange an appointment for such follow-up to be actioned. The evidence was that this did not happen. There was no follow-up. When Mr Richards was next seen in surgery on 5th October 2016, the x-rays were not discussed and there was no discussion of the requested follow-up with either the doctor, Mr Richards or his sister. The evidence was that Mr Richards was thought to be alarmed at the prospect that he might have lung cancer, from which his mother had died, and it was possible that this anxiety played a part in the prolongation or exacerbation of his depression leading to his suicide. Additionally, evidence was given that in the course of a Root Cause Serious Incident Investigation conducted by an independent panel at the behest of the mental health authority (North East London Foundation Trust) that documents were sent electronically by fax from agencies of the Trust, especially the home treatment team and/or the Redbridge Access and Assessment Brief Intervention Team, which the GP surgery did not act upon although the Trust had received successful transmission reports generated by the fax machine. The features of: a) failure to act upon the request in the A&E discharge summary; b) failure to have a contingency system or audit in place to ensure that such failures are not missed; c) failure to include reference to the attendance at A&E and the discharge summary generated as a result of it, in the GP evidential report; d) and failure to act on fax documents sent to the surgery, all indicate a want of management control, lack of suitable procedures in place and a poor attention to documents received. ”
    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 Wanstead Place Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain contingency and audit controls for missed follow-up actions

    Wider context from the report

    “Mr Richards previous medical history included diagnoses of depression, and anxiety, for which he was treated at various times pharmacologically, by inpatient treatment in a secure hospital, by access to the Home Treatment Team and by community based mental health care. His history included self-harm and suicide attempt. His anxieties included financial worry, debt, unemployment and eviction. He attended A&E at Whipps Cross Hospital on 23rd July 2016 for treatment of pain in his right loin. Whilst there he was x-rayed to the chest, which revealed a “shadow” on the right side. The hospital advised Mr Richards and his sister who attended with him that this matter would be raised with the GP, and he was informed that the hospital recommended follow-up in the chest clinic. The discharge summary recorded “disch for GP F/Up – to check progress” and also specifically noted the clinician’s comments which included “please arrange F/U in the chest clinic”. A letter was given to the patient as well as emailed to the GP surgery. The initial GP evidential witness report to the Coroner, prepared for submission to the Inquest, made no mention of this event. I heard evidence that the usual surgery protocol was that a reviewing doctor would assess all emailed reports received into the surgery, and in a case like this would instruct the surgery receptionist to contact the patient to arrange an appointment for such follow-up to be actioned. The evidence was that this did not happen. There was no follow-up. When Mr Richards was next seen in surgery on 5th October 2016, the x-rays were not discussed and there was no discussion of the requested follow-up with either the doctor, Mr Richards or his sister. The evidence was that Mr Richards was thought to be alarmed at the prospect that he might have lung cancer, from which his mother had died, and it was possible that this anxiety played a part in the prolongation or exacerbation of his depression leading to his suicide. Additionally, evidence was given that in the course of a Root Cause Serious Incident Investigation conducted by an independent panel at the behest of the mental health authority (North East London Foundation Trust) that documents were sent electronically by fax from agencies of the Trust, especially the home treatment team and/or the Redbridge Access and Assessment Brief Intervention Team, which the GP surgery did not act upon although the Trust had received successful transmission reports generated by the fax machine. The features of: a) failure to act upon the request in the A&E discharge summary; b) failure to have a contingency system or audit in place to ensure that such failures are not missed; c) failure to include reference to the attendance at A&E and the discharge summary generated as a result of it, in the GP evidential report; d) and failure to act on fax documents sent to the surgery, all indicate a want of management control, lack of suitable procedures in place and a poor attention to documents received. ”
    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 Wanstead Place Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on requested clinical follow-up

    Wider context from the report

    “Mr Richards previous medical history included diagnoses of depression, and anxiety, for which he was treated at various times pharmacologically, by inpatient treatment in a secure hospital, by access to the Home Treatment Team and by community based mental health care. His history included self-harm and suicide attempt. His anxieties included financial worry, debt, unemployment and eviction. He attended A&E at Whipps Cross Hospital on 23rd July 2016 for treatment of pain in his right loin. Whilst there he was x-rayed to the chest, which revealed a “shadow” on the right side. The hospital advised Mr Richards and his sister who attended with him that this matter would be raised with the GP, and he was informed that the hospital recommended follow-up in the chest clinic. The discharge summary recorded “disch for GP F/Up – to check progress” and also specifically noted the clinician’s comments which included “please arrange F/U in the chest clinic”. A letter was given to the patient as well as emailed to the GP surgery. The initial GP evidential witness report to the Coroner, prepared for submission to the Inquest, made no mention of this event. I heard evidence that the usual surgery protocol was that a reviewing doctor would assess all emailed reports received into the surgery, and in a case like this would instruct the surgery receptionist to contact the patient to arrange an appointment for such follow-up to be actioned. The evidence was that this did not happen. There was no follow-up. When Mr Richards was next seen in surgery on 5th October 2016, the x-rays were not discussed and there was no discussion of the requested follow-up with either the doctor, Mr Richards or his sister. The evidence was that Mr Richards was thought to be alarmed at the prospect that he might have lung cancer, from which his mother had died, and it was possible that this anxiety played a part in the prolongation or exacerbation of his depression leading to his suicide. Additionally, evidence was given that in the course of a Root Cause Serious Incident Investigation conducted by an independent panel at the behest of the mental health authority (North East London Foundation Trust) that documents were sent electronically by fax from agencies of the Trust, especially the home treatment team and/or the Redbridge Access and Assessment Brief Intervention Team, which the GP surgery did not act upon although the Trust had received successful transmission reports generated by the fax machine. The features of: a) failure to act upon the request in the A&E discharge summary; b) failure to have a contingency system or audit in place to ensure that such failures are not missed; c) failure to include reference to the attendance at A&E and the discharge summary generated as a result of it, in the GP evidential report; d) and failure to act on fax documents sent to the surgery, all indicate a want of management control, lack of suitable procedures in place and a poor attention to documents received. ”
    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 Wanstead Place Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on faxed clinical documents

    Wider context from the report

    “Mr Richards previous medical history included diagnoses of depression, and anxiety, for which he was treated at various times pharmacologically, by inpatient treatment in a secure hospital, by access to the Home Treatment Team and by community based mental health care. His history included self-harm and suicide attempt. His anxieties included financial worry, debt, unemployment and eviction. He attended A&E at Whipps Cross Hospital on 23rd July 2016 for treatment of pain in his right loin. Whilst there he was x-rayed to the chest, which revealed a “shadow” on the right side. The hospital advised Mr Richards and his sister who attended with him that this matter would be raised with the GP, and he was informed that the hospital recommended follow-up in the chest clinic. The discharge summary recorded “disch for GP F/Up – to check progress” and also specifically noted the clinician’s comments which included “please arrange F/U in the chest clinic”. A letter was given to the patient as well as emailed to the GP surgery. The initial GP evidential witness report to the Coroner, prepared for submission to the Inquest, made no mention of this event. I heard evidence that the usual surgery protocol was that a reviewing doctor would assess all emailed reports received into the surgery, and in a case like this would instruct the surgery receptionist to contact the patient to arrange an appointment for such follow-up to be actioned. The evidence was that this did not happen. There was no follow-up. When Mr Richards was next seen in surgery on 5th October 2016, the x-rays were not discussed and there was no discussion of the requested follow-up with either the doctor, Mr Richards or his sister. The evidence was that Mr Richards was thought to be alarmed at the prospect that he might have lung cancer, from which his mother had died, and it was possible that this anxiety played a part in the prolongation or exacerbation of his depression leading to his suicide. Additionally, evidence was given that in the course of a Root Cause Serious Incident Investigation conducted by an independent panel at the behest of the mental health authority (North East London Foundation Trust) that documents were sent electronically by fax from agencies of the Trust, especially the home treatment team and/or the Redbridge Access and Assessment Brief Intervention Team, which the GP surgery did not act upon although the Trust had received successful transmission reports generated by the fax machine. The features of: a) failure to act upon the request in the A&E discharge summary; b) failure to have a contingency system or audit in place to ensure that such failures are not missed; c) failure to include reference to the attendance at A&E and the discharge summary generated as a result of it, in the GP evidential report; d) and failure to act on fax documents sent to the surgery, all indicate a want of management control, lack of suitable procedures in place and a poor attention to documents received. ”
    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