Michael Patrick Joseph LOGUE · Prevention of Future Deaths report

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Issued 4 Nov 2015•Birmingham and Solihull

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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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

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

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. Central Surgery (Rugby)

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

  2. Central Surgery (Rugby)

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

  3. Central Surgery (Rugby)

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

  4. Central Surgery (Rugby)

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

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

  1. Central Surgery (Rugby)

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

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

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

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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.

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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 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

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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

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

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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

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