25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
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Concerns raised 14 Insufficiently detailed EDS referral information about low sodium and blood results View source Failure to consider chemical pathology flagging of particularly concerning results View source Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis View source No established GP practice system for recognition, assessment and management of electrolyte abnormalities View source Lack of GP routine vital sign monitoring when weight loss is a concern View source Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling View source Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage View source Lack of hospital or GP notes available to the post-mortem pathologist View source Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes View source Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations View source Insufficient communication from referral agents to the eating disorder service View source Poor GP documentation View source Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes View source Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium View source See 11 more concerns
Responses linked to these concerns
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AI-generated summary
Clare Serena Anke COOPER · 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
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
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× 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed EDS referral information about low sodium and blood results
Wider context from the report “6. Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a copy of the blood results ) and an opportunity was lost for its significance to be considered
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to consider chemical pathology flagging of particularly concerning results
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results .
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
Wider context from the report “8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the possibility of detecting individuals with an organic basis for the condition .
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation No established GP practice system for recognition, assessment and management of electrolyte abnormalities
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of GP routine vital sign monitoring when weight loss is a concern
Wider context from the report “3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder .
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital or GP notes available to the post-mortem pathologist
Wider context from the report “9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially in the young.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes
Wider context from the report “2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause .
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations
Wider context from the report “5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out , particularly in circumstances when there is no obvious cause of the low sodium.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication from referral agents to the eating disorder service
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Poor GP documentation
Wider context from the report “1. Poor GP documentation
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Woodlands Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder.
” Open source report
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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 Highlight to all clinicians the importance of monitoring, assessing and appropriately following up electrolyte abnormalities.
Verbatim wording from the response “handle abnormal pathology results as a result of this case. Unfortunately we do not consider that there are any specific system changes that can be implemented but I have highlighted to all clinicians the importance of monitoring and assessing electrolyte abnormalities and appropriate follow up.” Source location 2014-0345-Response-by-Woodlands-Surgery
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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 Objectively document weight loss through serial weight measurements.
Verbatim wording from the response “We have all agreed that all patients should have a proper assessment of their history and a full examination should be done. Routine vital signs should be recorded if they are clinically relevant. If a patient presents with weight loss then the weight loss needs to be objectively documented with serial weight measurements.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 Attach copies of all investigations to every patient referral letter.
Verbatim wording from the response “99% of referrals from Woodlands Surgery go to Surrey and Sussex Healthcare Trust (SASH). The Trust is linked in to the pathology software so for the vast majority of our referrals the hospital does have access to our patients’ pathology results. However from now on all patient referrals will have copies of all investigations (not just blood tests) attached with them to the referral letter.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.
Verbatim wording from the response “We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 Complete the BMJ hyponatraemia learning module and record the learning need in professional development plans for appraisal submission.
Verbatim wording from the response “We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison’s disease. I am now sure now that all of the doctors here at the practice have a fuller understanding of this rare condition. In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia. We will add this learning need to our PDP’s and will be submitting this for our appraisals. We have also invited ████████ Consultant Endocrinologist at East Surrey Hospital to give a lunchtime educational meeting here at the practice on hyponatraemia and Addison’s Disease. This is provisionally booked for Monday 13th October 2014.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 Submit anonymised consultation notes for assessment during doctors’ next appraisals.
Verbatim wording from the response “We have all agreed that the notes keeping in this case should have been better and may have compounded the issue relating to lack of continuity of care. In order to improve patient care and ensure that an episode like this is not repeated, doctors at the practice have agreed that as part of their ongoing personal development plan to submit anonymised consultation notes for their next appraisals. This will give a chance for each individual doctor’s appraiser to assess the quality of note keeping.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 Hold a practice educational meeting on hyponatraemia and Addison’s disease with a consultant endocrinologist.
Verbatim wording from the response “We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison’s disease. I am now sure now that all of the doctors here at the practice have a fuller understanding of this rare condition. In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia. We will add this learning need to our PDP’s and will be submitting this for our appraisals. We have also invited ████████ Consultant Endocrinologist at East Surrey Hospital to give a lunchtime educational meeting here at the practice on hyponatraemia and Addison’s Disease. This is provisionally booked for Monday 13th October 2014.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
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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 No specific system changes to handle abnormal pathology results can be implemented; clinicians have instead been reminded to monitor, assess and follow up abnormalities.
Verbatim wording from the response “The system at the practice at the time for identifying abnormal electrolyte results was that all results are seen by the patients’ usual registered doctor. It is the responsibility of the patients’ usual registered doctor to action and file the results. In relation to this case the results were seen and filed by Miss Cooper’s registered doctor. Miss Cooper was reviewed here at the practice within a week of each abnormal electrolyte result. The practice has considered what if any specific changes can be made to the way in which we” Source location 2014-0345-Response-by-Woodlands-Surgery
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations