Recipient

Wells Road Surgery

First report 27 Nov 2017•Latest report 27 Nov 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
Published responses: 100%
Concerns addressed: 3
Stated actions: 2

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.

100%published responses found

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

27 Nov2017
Avon
Concerns raised3
1. Failure to perform chest examinations
2. Failure to make clinical records
3. Failure to conduct clinical assessments in consultation rooms
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Add walk-in patients to the on-call triage list and obtain the on-call doctor’s advice, creating a prompt to document relevant information.
  Stated completed
2. Action
  Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.
  Stated completed
Respondent positions 2
1. Position
  The patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.
  Disputes the concern
1. Position
  The patient lacked features of acute severe asthma or severe chest infection, making home antibiotics with safety-netting clinically appropriate.
  Disputes the concern
AI-generated summary

Shaun Mark BERRYMAN · 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

Shaun Mark Berryman was found dead at his home address. The medical cause of death was recorded as morphine toxicity and acute bronchopneumonia, with the inquest conclusion recorded as drug-related. Concerns included a clinical assessment for a chest infection being conducted in a waiting area rather than a consultation room, no chest examination being performed, and no clinical record being made.

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 Wells Road Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to perform chest examinations
Wider context from the report
“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
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 Wells Road Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to make clinical records
Wider context from the report
“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
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 Wells Road Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct clinical assessments in consultation rooms
Wider context from the report
“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”
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
Add walk-in patients to the on-call triage list and obtain the on-call doctor’s advice, creating a prompt to document relevant information.

Verbatim wording from the response
“Secondly regarding writing in his clinical records; any ‘walk-in’ patients are now added to the on-call triage list by reception staff in anticipation of a potential assessment by the doctor, whilst the receptionist speaks to the on-call doctor to find out what their advice is. By adding their details to the on-call triage list, there is a visual reminder for both the doctor and receptionist to write any relevant information into the patient records. I want to re-iterate that my failure to write in Mr Berryman’s records was not a general sign of poor organisational skills, rather the lack of a visual reminder on the on-call triage list meant my usual back-up review at the end of the on-call shift did not work on this occasion.”

Source location
2017-0424-Response
Page 5 · response
Published 27 February 2018
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
Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.

Verbatim wording from the response
“Primarily the main issue was me seeing a patient in the waiting room and subsequently not being able to examine them properly. I realise that this situation must not happen again. Presently, I have made sure that all medically relevant conversation with a patient occur in my consulting room, so appropriate physical examination can be done in privacy.”

Source location
2017-0424-Response
Page 5 · response
Published 27 February 2018
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
The patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.

Verbatim wording from the response
“From the SEA meeting, Mrs Scally confirmed that Mr Berryman refused a formal appointment and she confirmed that she saw me speaking with him in the waiting room. If Mr Berryman had agreed to wait for a formal consultation, then I would have done an appropriate full physical respiratory examination and prescribed him medication based on his presentation. I accept that seeing Mr Berryman in the waiting room was far from ideal, but I took the opportunity to see a patient, who had not booked or requested a doctor appointment, based on my clinical judgement of the situation.”

Source location
2017-0424-Response
Page 3 · response
Published 27 February 2018
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
The patient lacked features of acute severe asthma or severe chest infection, making home antibiotics with safety-netting clinically appropriate.

Verbatim wording from the response
“I realise that seeing Mr Berryman at his convenience in the waiting room was not ideal and seeing him there prevented me from doing a formal consultation and full respiratory examination. But he did not present with features of acute severe asthma (as described above) or a severe chest infection (confusion and fast respiratory rate), I used my clinical judgement and I felt that treatment at home with oral antibiotics (Amoxicillin) was appropriate in this situation, but with the follow up advice (which I give to all patients who leave with oral antibiotics), which is: if the patient feels they are deteriorating in their health, they should call (NHS) 111 or if he feels he is having difficulty breathing, then he or a relative should call 999 for emergency admission to hospital.”

Source location
2017-0424-Response
Page 4 · response
Published 27 February 2018
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to perform chest examinations

Failure to make clinical records

Failure to conduct clinical assessments in consultation rooms

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 2

Respondent positions 2