PFD report

Doris Phoebe Miller · Prevention of Future Deaths report

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Issued 28 Nov 2013•Milton Keynes

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.

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Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
0

Of 4 recipients

Stated actions
0

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. Unavailability of a pulse oximeter in the GP surgery
    Part of recurring concern: Unreliable provision, reliability and use of pulse oximetry
  2. Lack of an effective communication system between GP surgeries and district nurses
    Part of recurring concern: Unreliable communication in district nursing care coordinationPart of recurring concern: Unreliable multi-agency communication procedures
  3. Failure to provide the GP surgery with access to transferred patient records
    Part of recurring concern: Failure to reliably transfer medical records between healthcare organisationsPart of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unreliable consolidation and access to patients’ cross-service clinical risk information
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

Unavailability of a pulse oximeter in the GP surgery

Wider context from the report

“(3) During the inquest hearing it became apparent that the surgery at Broughton Gate did not have access to a pulse oximeter to measure Mrs Miller’s oxygenation. This is a relatively inexpensive item and should perhaps be available in every doctor’s surgery throughout the country. ”

Is this part of a recurring concern?

Yes — Unreliable provision, reliability and use of pulse oximetry.

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 an effective communication system between GP surgeries and district nurses

Wider context from the report

“(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses. Again this gives rise to a concern that lives may be at risk. ”

Is this part of a recurring concern?

Yes — Unreliable communication in district nursing care coordination; Unreliable multi-agency communication procedures.

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 provide the GP surgery with access to transferred patient records

Wider context from the report

“(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery, following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records. Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk. ”

Is this part of a recurring concern?

Yes — Failure to reliably transfer medical records between healthcare organisations; Unreliable access to relevant clinical records for safe care; Unreliable consolidation and access to patients’ cross-service clinical risk information.

Open source report
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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