PFD report

Shre Kumar CHATTERJEE · Prevention of Future Deaths report

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Issued 18 Dec 2025•Hampshire, Portsmouth Southampton

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
3

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 raised3

  1. Blocking of direct booking with a patient's own GP for face-to-face assessment
    Part of recurring concern: Inadequate GP consultation provision for safe patient assessmentPart of recurring concern: Unclear and unreliable GP access and referral pathways
  2. Unavailability of blood tests and imaging in Urgent Care Centres
    Part of recurring concern: Failure to provide timely clinically required blood testsPart of recurring concern: Failure to provide timely urgent diagnostic investigations
  3. Failure of Urgent Care Centres to provide doctor examination
    Part of recurring concern: Failure to ensure complete clinical history and examinationPart of recurring concern: Failure to provide face-to-face clinical assessment when clinically indicated
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

Blocking of direct booking with a patient's own GP for face-to-face assessment

Wider context from the report

“During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”

Is this part of a recurring concern?

Yes — Inadequate GP consultation provision for safe patient assessment; Unclear and unreliable GP access and referral pathways.

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

Unavailability of blood tests and imaging in Urgent Care Centres

Wider context from the report

“During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinically required blood tests; Failure to provide timely urgent diagnostic investigations.

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 of Urgent Care Centres to provide doctor examination

Wider context from the report

“During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”

Is this part of a recurring concern?

Yes — Failure to ensure complete clinical history and examination; Failure to provide face-to-face clinical assessment when clinically indicated.

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