PFD report

Carol Leeming · Prevention of Future Deaths report

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Issued 25 Sep 2023•Newcastle and North Tyneside

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
11

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 raised4

  1. Unavailability of online induction training for new joiners unable to attend in-person induction training
    Part of recurring concern: Failure to provide adequate and accessible staff induction
  2. Regular turnover of GPs working for short periods as part of their training
    Part of recurring concern: Failure to provide continuity of care staffing
  3. Staff confusion about the functioning and capabilities of call-centre systems
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.1

  1. Action

    Require completion of induction before assigning GP trainees work, using quarterly sessions and attendance records to control shift allocation.

    Stated by TotallyStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.

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

  1. Position

    Physical induction is required before work, so more frequent sessions and access controls remove the need for online induction before commencement.

    Stated by TotallyExisting 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

Unavailability of online induction training for new joiners unable to attend in-person induction training

Wider context from the report

“(2) There was no facility for online induction training to be made available to new joiners who were unable to attend in person induction training; ”

Is this part of a recurring concern?

Yes — Failure to provide adequate and accessible staff induction.

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

Regular turnover of GPs working for short periods as part of their training

Wider context from the report

“(4) Evidence was given at the inquest that there was a regular turnover of different GPs working for Vocare for short periods as part of their training. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing.

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

Staff confusion about the functioning and capabilities of call-centre systems

Wider context from the report

“(3) There was evidence of confusion amongst staff about the functioning and capabilities of the systems in place at the call centre; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 requirement for out-of-hours GPs to complete induction training before starting work

Wider context from the report

“(1) There was no requirement for the out of hours GP to have completed induction training prior to starting work for Vocare; ”

Is this part of a recurring concern?

Yes — Failure to provide adequate and accessible staff induction.

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

Require completion of induction before assigning GP trainees work, using quarterly sessions and attendance records to control shift allocation.

Verbatim wording from the response

“Although it was a requirement for the GP trainee to attend the induction, no alternative dates were offered to him in spite of his repeated requests. Induction sessions were run 6 monthly in line with the GP trainee intakes. However, inductions are now being run quarterly so GP trainees have two options to attend the course and should not be in a position where they have not attended an induction prior to working for the organisation. If they cannot attend then they do not work for us. They do their urgent care training in-hours in surgeries and not in the out of hours period with Vocare. Induction is a pre-requisite to work. The administrative team takes a register of who is at induction and only these doctors are given shifts to work.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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

Physical induction is required before work, so more frequent sessions and access controls remove the need for online induction before commencement.

Verbatim wording from the response

“Although it was a requirement for the GP trainee to attend the induction, no alternative dates were offered to him in spite of his repeated requests. Induction sessions were run 6 monthly in line with the GP trainee intakes. However, inductions are now being run quarterly so GP trainees have two options to attend the course and should not be in a position where they have not attended an induction prior to working for the organisation. If they cannot attend then they do not work for us. They do their urgent care training in-hours in surgeries and not in the out of hours period with Vocare. Induction is a pre-requisite to work. The administrative team takes a register of who is at induction and only these doctors are given shifts to work.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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 identified training and system concerns did not affect Mrs Leeming’s outcome, which was attributed to natural causes.

Verbatim wording from the response

“We note your acknowledgment in your inquest conclusion that the above concerns did not affect the outcome for Mrs Leeming, as the conclusion of the inquest was natural causes, the medical cause of death being 1a) Coronary artery atheroma; 2) Chronic Obstructive Pulmonary Disease.”

Source location

Response from Totally
Page 1 · response
Published 26 September 2023

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.10

  1. 1

    Implement improved GP supervisor support, including clarified responsibilities, shadowing and completion of competency-framework portfolios.

    Stated by TotallyStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
  2. 2

    Provide refresher training so staff understand the business continuity plan for potential PACCS system failures.

    Stated by TotallyStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
  3. 3

    Deliver induction through six bite-sized slide sessions with breaks to improve usability and cover IT systems and operational matters.

    Stated by TotallyStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
  4. 4

    Display business continuity posters and place desktop reminders to reinforce staff responses to PACCS system failures.

    Stated by TotallyStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
  5. 5

    Invest at least £1.5 billion to create 50 million additional general practice appointments by growing and diversifying the workforce.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
  6. 6

    Provide additional ambulance funding, 800 new ambulances, six ambulance hubs and 42 new or upgraded discharge lounges to increase capacity and reduce delays.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
  7. 7

    Expand falls response services nationally through community teams supporting people who fall at home or in care homes.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
  8. 8

    Launch the next phase of the National Recruitment Campaign and increase international recruitment of social care workers.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
  9. 9

    Deliver 5,000 additional staffed permanent hospital beds and fund measures to reduce delayed discharges and ambulance handover delays.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
  10. 10

    Publish the delivery plan for recovering urgent and emergency care services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.

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 improved GP supervisor support, including clarified responsibilities, shadowing and completion of competency-framework portfolios.

Verbatim wording from the response

“Although it is recognised that there is now full interoperability between services in the North East via the use of the PACCS system, there is always the chance that it may fail. All staff have undergone refresher training and are therefore aware of the business continuity plan should this happen. Posters are in situ and reminders have been placed on individual desk tops as an adjunct to this. An improved process for supporting the GP supervisors is in place such that all supervisors fully understand their responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is acknowledged that the organisation works collaboratively with the Deanery in this regard.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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 refresher training so staff understand the business continuity plan for potential PACCS system failures.

Verbatim wording from the response

“Although it is recognised that there is now full interoperability between services in the North East via the use of the PACCS system, there is always the chance that it may fail. All staff have undergone refresher training and are therefore aware of the business continuity plan should this happen. Posters are in situ and reminders have been placed on individual desk tops as an adjunct to this. An improved process for supporting the GP supervisors is in place such that all supervisors fully understand their responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is acknowledged that the organisation works collaboratively with the Deanery in this regard.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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

Deliver induction through six bite-sized slide sessions with breaks to improve usability and cover IT systems and operational matters.

Verbatim wording from the response

“In addition, following feedback from the attendees it has been agreed that the induction sessions will be run in bite-sized sessions to increase their usefulness. Thus, the induction is divided into 6 slide shows with breaks in-between. The induction covers IT systems and operational matters, thus giving clinicians the tools, they need to ensure that safe high-quality care is delivered.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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

Display business continuity posters and place desktop reminders to reinforce staff responses to PACCS system failures.

Verbatim wording from the response

“Although it is recognised that there is now full interoperability between services in the North East via the use of the PACCS system, there is always the chance that it may fail. All staff have undergone refresher training and are therefore aware of the business continuity plan should this happen. Posters are in situ and reminders have been placed on individual desk tops as an adjunct to this. An improved process for supporting the GP supervisors is in place such that all supervisors fully understand their responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is acknowledged that the organisation works collaboratively with the Deanery in this regard.”

Source location

Response from Totally
Page 2 · response
Published 26 September 2023

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

Invest at least £1.5 billion to create 50 million additional general practice appointments by growing and diversifying the workforce.

Verbatim wording from the response

“Finally, in primary care, we have already committed to invest at least £1.5 billion to create an additional 50 million general practice appointments by 2024, by growing and diversifying the workforce, which should improve access for patients. We estimate that this plan will deliver over a million more appointments this winter by bolstering general practice teams with other professionals who can help them. This will reduce the need for A&E and emergency care getting patients the treatment where they need it.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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 additional ambulance funding, 800 new ambulances, six ambulance hubs and 42 new or upgraded discharge lounges to increase capacity and reduce delays.

Verbatim wording from the response

“Ambulance services are receiving £200 million of additional funding this year to grow capacity and improve response times alongside 800 new ambulances, including specialist mental health ambulances. Backed by nearly £50 million, the delivery of 6 new ambulance hubs and 42 new or upgraded discharge lounges will cut unnecessary delays, helping get ambulances back on the road faster.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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

Expand falls response services nationally through community teams supporting people who fall at home or in care homes.

Verbatim wording from the response

“Further, the NHS has expanded falls response services right across the country, where local community teams are sent to help people who have fallen in their home or in care homes, saving vital ambulance resource and unnecessary trips to hospital.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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

Launch the next phase of the National Recruitment Campaign and increase international recruitment of social care workers.

Verbatim wording from the response

“To build capacity in social care ahead of this winter, we will launch the next phase of our National Recruitment Campaign to encourage more people to join social care. We are also boosting international recruitment of care workers, with a further £15 million invested this year and more next year.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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

Deliver 5,000 additional staffed permanent hospital beds and fund measures to reduce delayed discharges and ambulance handover delays.

Verbatim wording from the response

“To increase hospital capacity and reduce waits, the delivery plan will deliver 5,000 more staffed, permanent beds this year compared to 2022-23 plans, backed up £1bn of dedicated funding. This is alongside £1.6 billion over the next 2 years to reduce the numbers of beds occupied by patients ready to be discharged helping improve flow through hospitals and reducing ambulance handover delays.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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

Publish the delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response

“We recognise the pressures the ambulance service is facing which is why we published our delivery plan for recovering urgent and emergency care services. This aims to deliver one of the fastest and longest sustained improvements in waiting times in the NHS's history reducing Category 2 response times to 30 minutes this year, with further improvements towards pre-pandemic levels next year.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 26 September 2023

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