PFD report

Ronald Leslie HARRIS · Prevention of Future Deaths report

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Issued 4 Oct 2023•Herefordshire

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
1

Of 1 recipient

Stated actions
7

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 telephone patients as requested or advised
    Part of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires it
  2. Failure of triage clinicians to be aware of routine appointment waiting times
    Part of recurring concern: Unreliable GP appointment triage for determining clinical urgency
  3. Incomplete triage documentation
    Part of recurring concern: Unreliable documentation of clinical triage decisions and advice
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.

    Stated by Hereford Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 18 October 2023.
  2. Action

    Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.

    Stated by Hereford Medical GroupStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  3. Action

    Implement a process allowing clinicians to listen to the patient’s phone call when an online triage form is unavailable.

    Stated by Hereford Medical GroupStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.

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

  1. Position

    The existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.

    Stated by Hereford Medical GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 telephone patients as requested or advised

Wider context from the report

“(2) The patient was not telephoned as requested and as advised they would be. ”

Is this part of a recurring concern?

Yes — Failure to reliably telephone patients when follow-up or assessment requires it.

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 triage clinicians to be aware of routine appointment waiting times

Wider context from the report

“(3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. ”

Is this part of a recurring concern?

Yes — Unreliable GP appointment triage for determining clinical urgency.

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

Incomplete triage documentation

Wider context from the report

“(1) Triage documentation was not fully completed. ”

Is this part of a recurring concern?

Yes — Unreliable documentation of clinical triage decisions and advice.

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 a revised protocol for triaging patients with mental health problems

Wider context from the report

“(4) The Deceased died on the 5th June 2023. The Inquest was told that a significant event meeting on the 9th August 2023 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken. The Inquest was held on the 27th September 2023 no revised protocol was advised. ”

Is this part of a recurring concern?

Yes — Unsafe management of operational protocol changes.

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 consider telephone call transcripts during triage

Wider context from the report

“(3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care.

Open source report

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

Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.

Verbatim wording from the response

“We have taken significant measures to reduce the wait time for routine appointments by increasing the number of available routine appointments. The wait for a routine appointment is under continuous review and our current wait is around approximately 4 weeks. In future, this information will be communicated to all staff on a weekly basis using the staff newsletter.”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

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

Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.

Verbatim wording from the response

“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

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

Implement a process allowing clinicians to listen to the patient’s phone call when an online triage form is unavailable.

Verbatim wording from the response

“We also noted learning from this event and have since implemented a new process whereby if an online form was not available for a clinician, they are able to arrange to listen to the phone call.”

Source location

Response from Hereford Medical Group
Page 1 · response
Published 18 October 2023

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

Update reception protocols so receptionists telephone patients first to explain the GP’s triage decision.

Verbatim wording from the response

“When patients complete a triage form they are asked to indicate their preference for contact including phone or SMS. We have updated the protocols that the team follows and the reception team, who usually undertake the actions indicated following triage, now telephone the patient in the first instance to advise on the GPs triage decision.”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

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 existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.

Verbatim wording from the response

“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

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 telephone call contained nothing that would have influenced the GP’s triaging outcome.

Verbatim wording from the response

“All triaging GPs are aware of how to find appropriate triage appointments. Calls are not routinely transcribed at the practice; when the Significant Event Analysis (SEA) meeting took place we ensured that a copy of the transcription was available to confirm what the receptionist advised was reflected in the call. We believe that nothing was discussed in the telephone call that would have influenced the triaging outcome.”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

Open published response

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.3

  1. 1

    Deliver a lunchtime training session for GPs on mental health.

    Stated by Hereford Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 18 October 2023.
  2. 2

    Increase the number of available routine appointments to reduce waiting times.

    Stated by Hereford Medical GroupStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  3. 3

    Deliver protected education on triaging, including clinical considerations, the triage process and protocols.

    Stated by Hereford Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 18 October 2023.

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

Deliver a lunchtime training session for GPs on mental health.

Verbatim wording from the response

“making sure that triaging GPs are aware of the next available routine and soon appointment slots. However, as part of regular and ongoing training for GPs, one of the lunchtime sessions over the next month will be on Mental Health. In addition, the next protected education time in January will be focused on triaging, including clinical considerations and the triage process and protocols.”

Source location

Response from Hereford Medical Group
Page 3 · response
Published 18 October 2023

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

Increase the number of available routine appointments to reduce waiting times.

Verbatim wording from the response

“We have taken significant measures to reduce the wait time for routine appointments by increasing the number of available routine appointments. The wait for a routine appointment is under continuous review and our current wait is around approximately 4 weeks. In future, this information will be communicated to all staff on a weekly basis using the staff newsletter.”

Source location

Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023

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

Deliver protected education on triaging, including clinical considerations, the triage process and protocols.

Verbatim wording from the response

“making sure that triaging GPs are aware of the next available routine and soon appointment slots. However, as part of regular and ongoing training for GPs, one of the lunchtime sessions over the next month will be on Mental Health. In addition, the next protected education time in January will be focused on triaging, including clinical considerations and the triage process and protocols.”

Source location

Response from Hereford Medical Group
Page 3 · response
Published 18 October 2023

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