PFD report

Lisa Webb · Prevention of Future Deaths report

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Issued 9 May 2014•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.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 use pulse oximetry in respiratory assessment
    Part of recurring concern: Unreliable provision, reliability and use of pulse oximetry
  2. Failure to measure and record peak flow rate
    Part of recurring concern: Unreliable asthma care and management
  3. Failure to enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation
    Part of recurring concern: Unreliable asthma care and management
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.1

  1. Action

    Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.

    Stated by Abbeyslade SurgeryStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Diazepam was prescribed because the known symptoms were not contraindicated; sleep apnoea was undisclosed and would have changed the prescribing decision.

    Stated by Abbeyslade SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 use pulse oximetry in respiratory assessment

Wider context from the report

“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

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

Failure to measure and record peak flow rate

Wider context from the report

“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

Is this part of a recurring concern?

Yes — Unreliable asthma care and 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

Failure to enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation

Wider context from the report

“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

Is this part of a recurring concern?

Yes — Unreliable asthma care and 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

Failure to record respiratory and pulse rates

Wider context from the report

“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of required observations in care and custody.

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 avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress

Wider context from the report

“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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

Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.

Verbatim wording from the response

“Action: Since Ms Webb’s death I make sure that during consultations I check the past history of significant problems and reviews, checks done and review previous consultations. I also check to see if there are any reviews outstanding and either complete them myself or ask the patient to make an appointment at reception for a review. I also record this advice within the patient’s electronic record.”

Source location

2014-0213-Response-by-Basildon-Road-Surgery
Page 1 · response
Published 9 May 2014

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

Diazepam was prescribed because the known symptoms were not contraindicated; sleep apnoea was undisclosed and would have changed the prescribing decision.

Verbatim wording from the response

“At the time I did not know that Ms Webb had sleep Apnoea. She had never indicated any symptoms to suggest that she had this condition and the symptoms she described on the day were not contraindicated with Diazepam.”

Source location

2014-0213-Response-by-Basildon-Road-Surgery
Page 2 · response
Published 9 May 2014

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.2

  1. 1

    Continue keeping up to date with clinical guidelines and complete continuing professional development courses covering patients’ diseases and medical conditions.

    Stated by Abbeyslade SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  2. 2

    Make more detailed and comprehensive electronic consultation notes, including information provided by patients.

    Stated by Abbeyslade SurgeryStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.

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 keeping up to date with clinical guidelines and complete continuing professional development courses covering patients’ diseases and medical conditions.

Verbatim wording from the response

“I shall continue to keep abreast of the latest guidelines and to maintain and improve my knowledge by continuing my CPD. I have undertaken a number of courses in order to consolidate, update and improve my knowledge in the following areas:”

Source location

2014-0213-Response-by-Basildon-Road-Surgery
Page 4 · response
Published 9 May 2014

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

Make more detailed and comprehensive electronic consultation notes, including information provided by patients.

Verbatim wording from the response

“I understand that comprehensive medical records are essential for good patient care and I have improved my record keeping and I make more detailed notes.”

Source location

2014-0213-Response-by-Basildon-Road-Surgery
Page 1 · response
Published 9 May 2014

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