York House Surgery

Private and voluntary organisations · Multi-service care provider

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First report 18 Mar 2014•Latest report 18 Mar 2014

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

18 Mar2014
Manchester North
Concerns raised9
1. Failure to make case-specific referrals through the single point of entry process
2. Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning
3. Unnecessarily bureaucratic and deterrent processes for accessing mental health services
1. Unavailability of direct referral to in-house community-based psychiatrists for new patients
2. Failure to ensure medically qualified practitioner management of single point of entry triage
3. Restrictions on cross-Clinical Commissioning Group referrals without special approval
4. Failure of contemporaneous record keeping to support clinical recollections
5. Failure to use recognised assessment tools in clinical evaluation
6. Failure to assess medication appropriateness in light of patients’ mental health history
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

David Gary Chatburn · 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

David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to make case-specific referrals through the single point of entry process
Wider context from the report
“4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process. Such discussions were not necessarily case specific in any event but rather, general in nature. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning
Wider context from the report
“1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan. The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions. Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt he did. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Unnecessarily bureaucratic and deterrent processes for accessing mental health services
Wider context from the report
“7. That the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent. GPs can no longer simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of direct referral to in-house community-based psychiatrists for new patients
Wider context from the report
“3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist, thus effectively defeating the object. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure medically qualified practitioner management of single point of entry triage
Wider context from the report
“8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report
“9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same. In order to do so, a ‘special case’ must be argued. This potentially limits patient (and practitioner) accessibility and treatment. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure of contemporaneous record keeping to support clinical recollections
Wider context from the report
“5. That the GP’s recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to use recognised assessment tools in clinical evaluation
Wider context from the report
“6. That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased. He felt that they were ineffective and of little, if any, value. ”
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess medication appropriateness in light of patients’ mental health history
Wider context from the report
“2. That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient’s past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists. ”
Open source report

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 raised9

Failure to make case-specific referrals through the single point of entry process

Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning

Unnecessarily bureaucratic and deterrent processes for accessing mental health services

Unavailability of direct referral to in-house community-based psychiatrists for new patients

Failure to ensure medically qualified practitioner management of single point of entry triage

Restrictions on cross-Clinical Commissioning Group referrals without special approval

Failure of contemporaneous record keeping to support clinical recollections

Failure to use recognised assessment tools in clinical evaluation

Failure to assess medication appropriateness in light of patients’ mental health history