Maurice Leech · Prevention of Future Deaths report

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Issued 23 Aug 2021•Manchester South

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised3

  1. Failure to provide physical examination during GP consultations
    Part of recurring concern: Failure to perform clinically indicated physical examinationsPart of recurring concern: Inadequate GP consultation provision for safe patient assessment
  2. Lack of NICE guidance for consistent management of femur fractures in elderly patients
    Part of recurring concern: Inadequate clinical guidance for fracture management
  3. Lack of support for vulnerable patients during hospital assessment
    Part of recurring concern: Inadequate support for vulnerable patients during healthcare assessment and decisions

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. NHS England

    Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.

  2. NHS England

    Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.

  3. Department of Health and Social Care

    Publish the plan for improving patient access and supporting general practice.

  4. Department of Health and Social Care

    Provide a £250 million Winter Access Fund to improve access to GP practice services.

  5. Department of Health and Social Care

    Continue supporting general practice to maintain and improve patient access to care.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. NHS England

    Existing remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Department of Health and Social Care

    Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Department of Health and Social Care

    There is not a lack of guidance on periprosthetic femoral fracture treatment, fracture pain management or palliative care.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. Department of Health and Social Care

    Local NHS Trusts are responsible for determining hospital visiting arrangements within national principles and their own safety assessments.

    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 provide physical examination during GP consultations

Wider context from the report

“1. The inquest heard evidence that pre Covid Mr Leech would have been examined face to face by the GP rather than a telephone consultation without an examination. The evidence indicated that a physical examination would probably have resulted in Mr Leech being referred back to hospital at an earlier stage. ”

Is this part of a recurring concern?

Yes — Failure to perform clinically indicated physical examinations; Inadequate GP consultation provision for safe patient assessment.

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 NICE guidance for consistent management of femur fractures in elderly patients

Wider context from the report

“3. The inquest heard that he was in significant pain from the fracture to the femur. Unlike the position relating to a fracture to the neck of femur there is no NICE guidance for treatment of such fractures to ensure a consistent approach to management of them in the elderly across the NHS. This included in Mr Leech’s case how to effectively manage his pain and the impact of that on his overall health. ”

Is this part of a recurring concern?

Yes — Inadequate clinical guidance for fracture management.

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 support for vulnerable patients during hospital assessment

Wider context from the report

“2. Mr Leech was very vulnerable and a poor historian. Due to Covid he was sent alone to hospital and seen alone there. The evidence before the inquest was that if support had been available a more accurate picture of his baseline and needs would have assisted staff in treating him and potentially identifying that he should not be discharged back to the care home and that a fracture would not have been missed. ”

Is this part of a recurring concern?

Yes — Inadequate support for vulnerable patients during healthcare assessment and decisions.

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

Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.

Verbatim wording from the response

“The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published”

Source location

2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Page 1 · response
Published 26 August 2021

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

Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.

Verbatim wording from the response

“Professional guidance published by the General Medical Council sets out high level principles of good practice expected of everyone when consulting and or prescribing remotely for the patient https://www.gmc-uk.org/ethical-guidance/learning-materials/remote-prescribing-high-level-principles and guidance to support shared decision making https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent.”

Source location

2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Page 2 · response
Published 26 August 2021

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

Publish the plan for improving patient access and supporting general practice.

Verbatim wording from the response

“The Department and NHSEI continue to support general practice, as we emerge from the pandemic, to maintain and improve access to care for patients. On 14 October 2021, the Government and NHSEI published Our plan for improving access for patients and supporting general practice³. The plan includes an investment of £250 million in a Winter Access Fund to improve access to GP practice services.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 2 · response
Published 26 August 2021

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

Provide a £250 million Winter Access Fund to improve access to GP practice services.

Verbatim wording from the response

“The Department and NHSEI continue to support general practice, as we emerge from the pandemic, to maintain and improve access to care for patients. On 14 October 2021, the Government and NHSEI published Our plan for improving access for patients and supporting general practice³. The plan includes an investment of £250 million in a Winter Access Fund to improve access to GP practice services.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 2 · response
Published 26 August 2021

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

Continue supporting general practice to maintain and improve patient access to care.

Verbatim wording from the response

“The Department and NHSEI continue to support general practice, as we emerge from the pandemic, to maintain and improve access to care for patients. On 14 October 2021, the Government and NHSEI published Our plan for improving access for patients and supporting general practice³. The plan includes an investment of £250 million in a Winter Access Fund to improve access to GP practice services.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 2 · response
Published 26 August 2021

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

Existing remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.

Verbatim wording from the response

“The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published”

Source location

2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Page 1 · response
Published 26 August 2021

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

Existing guidance, procedures, training and safety resources are considered sufficient to support safe remote general practice consultations.

Verbatim wording from the response

“Throughout the pandemic, NHSEI provided guidance to general practice and continually updated standard operating procedures to ensure that changing services could operate safely. NHSEI set out clear expectations that general practices offer face to face appointments alongside remote appointments (telephone and online), and that clinical appropriateness and patient preference should be taken into account to determine the most appropriate consultation method. NHSEI has also supported general practices in how best to communicate with their population on how to access services. Further details on guidance and standard operating procedures can be found on the NHSEI website¹.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 2 · response
Published 26 August 2021

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

There is not a lack of guidance on periprosthetic femoral fracture treatment, fracture pain management or palliative care.

Verbatim wording from the response

“In relation to your concern about guidance for the treatment of fractures to the femur, you may wish to note that while NICE Clinical Guideline 124: Hip fracture: management⁴, does not make specific recommendations on the management of this type of fracture (periprosthetic), it does cover the use of analgesia (see section 1.4) and multidisciplinary management (section 1.8) of people with hip fracture. I am advised by NICE that it is reasonable to expect that Clinical Guideline 124 could be applied to people with periprosthetic femoral fracture, such as Mr Leech.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 3 · response
Published 26 August 2021

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

Local NHS Trusts are responsible for determining hospital visiting arrangements within national principles and their own safety assessments.

Verbatim wording from the response

“Since the end of the national lockdown in England, visiting in hospitals is now subject to the discretion of local NHS Trusts, based on the national principles, which will make their own assessment as to the visiting arrangements that can safely be put in place. Careful hospital visiting policies remain appropriate while COVID-19 continues to be in general circulation and organisations can exercise discretion where COVID-19 rates are higher. The health, safety and wellbeing of patients, communities and staff remains the priority.”

Source location

2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 3 · response
Published 26 August 2021

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