Wells Road Surgery

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First report 27 Nov 2017•Latest report 27 Nov 2017

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
3

Across all linked responses

Stated actions
2

Described in responses

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.

  1. Avon

    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
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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