PFD report

Jennifer Louise Handy · Prevention of Future Deaths report

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Issued 5 Apr 2019•South Wales Central

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

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 raised2

  1. Failure to complete investigations and inquests
  2. Failure to ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned
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

    Establish professional guidance requiring doctors to disclose relevant disciplinary findings made by professional bodies worldwide.

    Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  2. Action

    Establish professional guidance requiring doctors to cooperate with formal inquiries and complaints procedures and provide relevant information.

    Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. Action

    Provide public online access to doctors’ fitness-to-practise histories and registration restrictions through the List of Registered Medical Practitioners.

    Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Existing systems, including the public medical register, sufficiently allow employers to access doctors’ fitness-to-practise information.

    Stated by General Medical CouncilExisting 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 complete investigations and inquests

Wider context from the report

“No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced. It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question. The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete, and the doctor in question has been unable to learn from the issues raised. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned

Wider context from the report

“No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced. It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question. The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete, and the doctor in question has been unable to learn from the issues raised. ”

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

Establish professional guidance requiring doctors to disclose relevant disciplinary findings made by professional bodies worldwide.

Verbatim wording from the response

“In addition, GMC guidance also sets a requirement for doctors to disclose relevant disciplinary information to the GMC. Specifically, paragraph 75 of GMP states that... 'You must tell us without delay if, anywhere in the world another professional body has made a finding against your registration as a result of fitness to practise procedures.'”

Source location

2019-0121-Response-by-General-Medical-Council
Page 5 · response
Published 9 June 2019

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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

Establish professional guidance requiring doctors to cooperate with formal inquiries and complaints procedures and provide relevant information.

Verbatim wording from the response

“There are provisions in the GMC’s main guidance document in relation to a doctor’s professional obligation to assist with formal proceedings.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 3 · response
Published 9 June 2019

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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

Provide public online access to doctors’ fitness-to-practise histories and registration restrictions through the List of Registered Medical Practitioners.

Verbatim wording from the response

“There are currently systems in place so that employers can access information about matters relating to a doctor’s fitness to practise.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 5 · response
Published 9 June 2019

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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

Contact the Assistant Medical Director for Professional Regulation and Standards when a departing doctor may have ongoing GMC concerns.

Verbatim wording from the response

“Learning for the Health Board The Claims Team were unaware there was an investigation by the GMC, that the Registrar had surrendered his license to practice, and he had relocated to Sri Lanka. From here on, if a doctor has left the Health Board, contact will be made with the Assistant Medical Director for Professional Regulation and Standards to establish whether there are any ongoing concerns/issues in relation to the GMC.”

Source location

2019-0121-Response-by-University-Health-Board
Page 1 · response
Published 9 June 2019

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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 systems, including the public medical register, sufficiently allow employers to access doctors’ fitness-to-practise information.

Verbatim wording from the response

“There are currently systems in place so that employers can access information about matters relating to a doctor’s fitness to practise.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 5 · response
Published 9 June 2019

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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 statutory requirements and powers sufficiently ensure that GMC-registered doctors maintain effective contact details.

Verbatim wording from the response

“The Act already makes provision for the GMC to take action on a doctor’s registration for failing to maintain an effective registered address.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 2 · response
Published 9 June 2019

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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 no legal basis to require doctors to provide contact details after their GMC registration has ended.

Verbatim wording from the response

“In terms of the first interpretation, the GMC’s statutory powers extend only to doctors who hold GMC registration. As such, there is no legal basis to require doctors to provide their contact details to the GMC once their registration has ended.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 3 · response
Published 9 June 2019

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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 GMC cannot legally compel doctors to engage in coroners’ proceedings, although professional standards require cooperation with formal inquiries.

Verbatim wording from the response

“As explained above, the legal and professional requirements of doctors arise from legislation and professional standards documents produced by the GMC, as opposed to there being any contractual relationship between the parties.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 3 · response
Published 9 June 2019

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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 information-sharing mechanisms and disclosure requirements sufficiently protect patient safety when doctors face proceedings in other jurisdictions.

Verbatim wording from the response

“There are already mechanisms in place for overseas regulators to share information regarding disciplinary action or criminal sanctions in relation to doctors working in other jurisdictions.”

Source location

2019-0121-Response-by-General-Medical-Council
Page 4 · response
Published 9 June 2019

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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