PFD report

Michael Patrick Joseph LOGUE · Prevention of Future Deaths report

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Issued 4 Nov 2015•Birmingham and Solihull

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

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 raised1

  1. Failure to carry out physical examinations during home visits
    Part of recurring concern: Failure to perform clinically indicated physical examinations
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 carry out physical examinations during home visits

Wider context from the report

“(1) The GP failed to carry out any physical examination of the patient during a home visit on 03/06/15. Mr Logue was complaining of not feeling at all well and of pain and was 5 days post biliary reconstruction surgery. ”

Is this part of a recurring concern?

Yes — Failure to perform clinically indicated physical examinations.

Open source report

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.4

  1. 1

    Complete a significant event review of the postoperative care case and identify practice improvements.

    Stated by Central Surgery (Rugby)Stated completedThe respondent said that this action was complete when they made their response on 4 November 2015.
  2. 2

    Carry out more detailed examinations of relevant postoperative patients and fully record the findings in patient notes.

    Stated by Central Surgery (Rugby)Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2015.
  3. 3

    Share the significant event with all clinicians to improve their work practices.

    Stated by Central Surgery (Rugby)Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2015.
  4. 4

    Contact the hospital to discuss improving communication supporting postoperative patient care.

    Stated by Central Surgery (Rugby)Stated in progressThe respondent said that this action was in progress when they made their response on 4 November 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Routine physical examination of every postoperative patient and use of a sepsis checklist were not considered necessary or routine practice.

    Stated by Central Surgery (Rugby)No action considered necessaryThe respondent said that no further action was needed.
  2. 2

    The hospital was considered responsible for being more proactive in contacting postoperative patients and improving follow-up communication.

    Stated by Central Surgery (Rugby)Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 a significant event review of the postoperative care case and identify practice improvements.

Verbatim wording from the response

“As requested I have reflected on the content of your report aimed at preventing future deaths. Central Surgery has discussed the case as a significant event as well.”

Source location

Response-by-Central-Surgery
Page 1 · response
Published 4 November 2015

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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

Carry out more detailed examinations of relevant postoperative patients and fully record the findings in patient notes.

Verbatim wording from the response

“The care of Mr Logue was discussed at a significant event analysis meeting at Central Surgery. My GP colleagues did not think that a routine examination of every post-operative patient was indicated and that use of a sepsis check list was not routine practice. However, it was agreed that in future it would be prudent to undertake a more detailed examination and to accurately and fully record the findings in any consultation. Some of the GPs in the practice have surgical training and considered that the hospital could be more proactive in contacting patients at home after major surgery. I have spoken to the hepatobiliary co-ordinator at University Hospitals, Birmingham and was advised that following a liver transplant, patients are contacted at home within one week of surgery, but that this is not the case following bile duct surgery.”

Source location

Response-by-Central-Surgery
Page 1 · response
Published 4 November 2015

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

Share the significant event with all clinicians to improve their work practices.

Verbatim wording from the response

“Following the Significant event review the following actions were agreed for immediate implementation:”

Source location

Response-by-Central-Surgery
Page 2 · response
Published 4 November 2015

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

Contact the hospital to discuss improving communication supporting postoperative patient care.

Verbatim wording from the response

“Following the significant event meeting I am now, on behalf of the practice, in the process of contacting Professor Muiesan to discuss with him how communication in relation to postoperative care can be improved.”

Source location

Response-by-Central-Surgery
Page 1 · response
Published 4 November 2015

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

Routine physical examination of every postoperative patient and use of a sepsis checklist were not considered necessary or routine practice.

Verbatim wording from the response

“The care of Mr Logue was discussed at a significant event analysis meeting at Central Surgery. My GP colleagues did not think that a routine examination of every post-operative patient was indicated and that use of a sepsis check list was not routine practice. However, it was agreed that in future it would be prudent to undertake a more detailed examination and to accurately and fully record the findings in any consultation. Some of the GPs in the practice have surgical training and considered that the hospital could be more proactive in contacting patients at home after major surgery. I have spoken to the hepatobiliary co-ordinator at University Hospitals, Birmingham and was advised that following a liver transplant, patients are contacted at home within one week of surgery, but that this is not the case following bile duct surgery.”

Source location

Response-by-Central-Surgery
Page 1 · response
Published 4 November 2015

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 hospital was considered responsible for being more proactive in contacting postoperative patients and improving follow-up communication.

Verbatim wording from the response

“The care of Mr Logue was discussed at a significant event analysis meeting at Central Surgery. My GP colleagues did not think that a routine examination of every post-operative patient was indicated and that use of a sepsis check list was not routine practice. However, it was agreed that in future it would be prudent to undertake a more detailed examination and to accurately and fully record the findings in any consultation. Some of the GPs in the practice have surgical training and considered that the hospital could be more proactive in contacting patients at home after major surgery. I have spoken to the hepatobiliary co-ordinator at University Hospitals, Birmingham and was advised that following a liver transplant, patients are contacted at home within one week of surgery, but that this is not the case following bile duct surgery.”

Source location

Response-by-Central-Surgery
Page 1 · response
Published 4 November 2015

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