PFD report

Shaun Mark BERRYMAN · Prevention of Future Deaths report

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Issued 27 Nov 2017•Avon

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
2

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. Failure to perform chest examinations
    Part of recurring concern: Failure to perform clinically indicated physical examinations
  2. Failure to make clinical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to conduct clinical assessments in consultation rooms
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.2

  1. Action

    Add walk-in patients to the on-call triage list and obtain the on-call doctor’s advice, creating a prompt to document relevant information.

    Stated by Wells Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.
  2. Action

    Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.

    Stated by Wells Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.

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

  1. Position

    The patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.

    Stated by Wells Road 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 perform chest examinations

Wider context from the report

“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”

Is this part of a recurring concern?

Yes — Failure to perform clinically indicated physical examinations.

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 make clinical records

Wider context from the report

“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”

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 conduct clinical assessments in consultation rooms

Wider context from the report

“In evidence it was established that Mr. Berryman was assessed by ████████ at Wells Road Surgery on 28.4.17 in respect of a chest infection but 1. The clinical assessment took place in the waiting area, not a consultation room; 2. No examination of the chest was performed; 3. No clinical record was made. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Add walk-in patients to the on-call triage list and obtain the on-call doctor’s advice, creating a prompt to document relevant information.

Verbatim wording from the response

“Secondly regarding writing in his clinical records; any ‘walk-in’ patients are now added to the on-call triage list by reception staff in anticipation of a potential assessment by the doctor, whilst the receptionist speaks to the on-call doctor to find out what their advice is. By adding their details to the on-call triage list, there is a visual reminder for both the doctor and receptionist to write any relevant information into the patient records. I want to re-iterate that my failure to write in Mr Berryman’s records was not a general sign of poor organisational skills, rather the lack of a visual reminder on the on-call triage list meant my usual back-up review at the end of the on-call shift did not work on this occasion.”

Source location

2017-0424-Response
Page 5 · response
Published 27 February 2018

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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

Conduct all medically relevant patient conversations in a consulting room to enable private physical examination.

Verbatim wording from the response

“Primarily the main issue was me seeing a patient in the waiting room and subsequently not being able to examine them properly. I realise that this situation must not happen again. Presently, I have made sure that all medically relevant conversation with a patient occur in my consulting room, so appropriate physical examination can be done in privacy.”

Source location

2017-0424-Response
Page 5 · response
Published 27 February 2018

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 patient refused to wait for a formal consultation, so the clinician assessed him informally between booked urgent patients.

Verbatim wording from the response

“From the SEA meeting, Mrs Scally confirmed that Mr Berryman refused a formal appointment and she confirmed that she saw me speaking with him in the waiting room. If Mr Berryman had agreed to wait for a formal consultation, then I would have done an appropriate full physical respiratory examination and prescribed him medication based on his presentation. I accept that seeing Mr Berryman in the waiting room was far from ideal, but I took the opportunity to see a patient, who had not booked or requested a doctor appointment, based on my clinical judgement of the situation.”

Source location

2017-0424-Response
Page 3 · response
Published 27 February 2018

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 patient lacked features of acute severe asthma or severe chest infection, making home antibiotics with safety-netting clinically appropriate.

Verbatim wording from the response

“I realise that seeing Mr Berryman at his convenience in the waiting room was not ideal and seeing him there prevented me from doing a formal consultation and full respiratory examination. But he did not present with features of acute severe asthma (as described above) or a severe chest infection (confusion and fast respiratory rate), I used my clinical judgement and I felt that treatment at home with oral antibiotics (Amoxicillin) was appropriate in this situation, but with the follow up advice (which I give to all patients who leave with oral antibiotics), which is: if the patient feels they are deteriorating in their health, they should call (NHS) 111 or if he feels he is having difficulty breathing, then he or a relative should call 999 for emergency admission to hospital.”

Source location

2017-0424-Response
Page 4 · response
Published 27 February 2018

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