PFD report

Nigel Handscomb · Prevention of Future Deaths report

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Issued 1 Aug 2018•Inner South London

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

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 raised5

  1. Failure to record chest examination findings
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Delays in recording consultation notes
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to record changes to medication-taking instructions
    Part of recurring concern: Failure to reliably record information and advice given to patientsPart of recurring concern: Inadequate recording of medication prescribing decisions
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 record chest examination findings

Wider context from the report

“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Delays in recording consultation notes

Wider context from the report

“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 record changes to medication-taking instructions

Wider context from the report

“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

Is this part of a recurring concern?

Yes — Failure to reliably record information and advice given to patients; Inadequate recording of medication prescribing decisions.

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 record swallow test findings

Wider context from the report

“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 record reported non-adherence to lithium medication

Wider context from the report

“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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