PFD report

Allan Robin Hamilton · Prevention of Future Deaths report

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Issued 23 Aug 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to provide effective triage of electronic patient contacts by medically qualified staff
    Part of recurring concern: Unreliable tracking and routing of electronic patient contacts in GP practices
  2. Failure to track and regularly check electronic patient contacts
    Part of recurring concern: Failure of case monitoring to identify cases requiring follow-upPart of recurring concern: Unreliable tracking and routing of electronic patient contacts in GP practices
  3. Lack of a clear audit trail for electronic patient contacts
    Part of recurring concern: Unreliable tracking and routing of electronic patient contacts in GP practices
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

    Implement monthly compliance audits of email response times and maintain email auditing as a standing SSP Health process.

    Stated by The Pike PracticeStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  2. Action

    Establish or update standard operating procedures for managing practice emails.

    Stated by The Pike PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 30 August 2024.

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

  1. Position

    Existing email controls and established electronic triage systems are considered appropriate for managing non-urgent communications and urgent-care routing.

    Stated by The Pike PracticeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide effective triage of electronic patient contacts by medically qualified staff

Wider context from the report

“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”

Is this part of a recurring concern?

Yes — Unreliable tracking and routing of electronic patient contacts in GP practices.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to track and regularly check electronic patient contacts

Wider context from the report

“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up; Unreliable tracking and routing of electronic patient contacts in GP practices.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a clear audit trail for electronic patient contacts

Wider context from the report

“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”

Is this part of a recurring concern?

Yes — Unreliable tracking and routing of electronic patient contacts in GP practices.

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

Implement monthly compliance audits of email response times and maintain email auditing as a standing SSP Health process.

Verbatim wording from the response

“In addition to the steps already mentioned, a monthly compliance audit has been implemented as a preventative measure. This audit reviews email response times to ensure the process remains efficient, with the automated patient response system fully operational.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Establish or update standard operating procedures for managing practice emails.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Existing email controls and established electronic triage systems are considered appropriate for managing non-urgent communications and urgent-care routing.

Verbatim wording from the response

“In the context of it being widely recognised that emails are not for medical use, The Pike Practice, along with all SSP practices, has a structured system for managing emails. Each email is read, reviewed, and directed to the appropriate staff member. While this process was in place and adhered to at the time of the incident, the email in question was not read within the usual 48-hour window, resulting in a delay of 24 hours beyond our usual internal standard timeframe.”

Source location

Response from SSP - The Pike Practice
Page 1 · response
Published 30 August 2024

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

Individual practices are responsible for establishing reliable systems and managing email correspondence according to their local requirements.

Verbatim wording from the response

“General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and as a result it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. If a”

Source location

Response from DHSC
Page 1 · response
Published 30 August 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Conduct HR discussions with staff concerning email handling and related safety processes.

    Stated by The Pike PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 30 August 2024.
  2. 2

    Provide educational communications through practice social media accounts about appropriate contact routes and urgent care.

    Stated by The Pike PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 30 August 2024.
  3. 3

    Update staff competency arrangements through the practice manager.

    Stated by The Pike PracticeStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  4. 4

    Meet with senior management to discuss email-handling safety measures.

    Stated by The Pike PracticeStatus unclearThe respondent did not make the status of this action clear when they made their response on 30 August 2024.
  5. 5

    Add the updated emergency email response to all SSP practice websites.

    Stated by The Pike PracticeStated plannedThe respondent said that this action was planned when they made their response on 30 August 2024.
  6. 6

    Update the automated email response across SSP practices to identify emergencies and direct patients to urgent medical services.

    Stated by The Pike PracticeStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The practice disputes that it directed patients away from phone contact or promoted email as a route for urgent medical concerns.

    Stated by The Pike PracticeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 HR discussions with staff concerning email handling and related safety processes.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Provide educational communications through practice social media accounts about appropriate contact routes and urgent care.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Update staff competency arrangements through the practice manager.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Meet with senior management to discuss email-handling safety measures.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Add the updated emergency email response to all SSP practice websites.

Verbatim wording from the response

“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location

Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024

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

Update the automated email response across SSP practices to identify emergencies and direct patients to urgent medical services.

Verbatim wording from the response

“As an outcome, upon review, we have updated the automated response to clearly reinforce what is commonly understood, i.e. that emails are for non-urgent enquiries only and the emergency services should be contacted in such circumstances. Please see below, the updated automated response:”

Source location

Response from SSP - The Pike Practice
Page 1 · response
Published 30 August 2024

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 practice disputes that it directed patients away from phone contact or promoted email as a route for urgent medical concerns.

Verbatim wording from the response

“It is important to note that at no point has The Pike Practice informed patients not to contact the practice by phone or encouraged the use of email. We do offer an online system which patients can chose to use should they wish. We have robust and clearly defined triage system for both calls and the online system. The practice does not expect or anticipate the use of emails as a means of making the practice aware of any medical issues – particularly anything serious. The emergency services (999 and even 111) are there for serious issues which is well known by the general patient population. This set-up is consistent with most GP surgeries in the UK. The coroner’s report should be amended to reflect these facts.”

Source location

Response from SSP - The Pike Practice
Page 1 · response
Published 30 August 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026