PFD report

Keith Smith · Prevention of Future Deaths report

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Issued 11 Mar 2024•East 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 demonstrate improvement in recording of patient calls
  2. Failure to demonstrate improvement in monitoring of GP call-backs to patients
  3. Failure to demonstrate improvement in escalation of patient enquiries to GPs
    Part of recurring concern: Unreliable escalation of patient telephone referrals to GPs
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.9

  1. Action

    Review and update communication, escalation and emergency policies through team engagement and a review process.

    Stated by Church Elm Lane Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2024.
  2. Action

    Provide staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.

    Stated by Church Elm Lane Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  3. Action

    Develop and use a Message Book protocol and telephone call supervision audit.

    Stated by Church Elm Lane Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.

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 demonstrate improvement in recording of patient calls

Wider context from the report

“The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 demonstrate improvement in monitoring of GP call-backs to patients

Wider context from the report

“The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 demonstrate improvement in escalation of patient enquiries to GPs

Wider context from the report

“The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients. ”

Is this part of a recurring concern?

Yes — Unreliable escalation of patient telephone referrals to GPs.

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

Review and update communication, escalation and emergency policies through team engagement and a review process.

Verbatim wording from the response

“Policy and Procedure Review”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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 staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.

Verbatim wording from the response

“Staff Training on Message Escalation: Training sessions were conducted to emphasize the importance of using the auditable message book for call escalation with direct communication with doctors for urgent concerns and screen messages not to be used for any patient-related queries. Two targeted internal training events with clinical and non-clinical staff have taken place to review and implement changes to the process of escalating clinical matters to the clinical team, and following up on this to see if this has been addressed and actioned (Appendix 1, 2, 3).”

Source location

Response from Church Elm Lane Medical Practice
Page 5 · response
Published 14 March 2024

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 use a Message Book protocol and telephone call supervision audit.

Verbatim wording from the response

“Following regular meetings with staff we have developed a Message Book protocol (Appendix 9) and a call supervision audit (Appendix 7)”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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 regular communication audits, call listening, patient-feedback reviews and training-adherence evaluations.

Verbatim wording from the response

“Objective: Implement a monitoring and evaluation framework to regularly assess the effectiveness of communication practices and protocols.”

Source location

Response from Church Elm Lane Medical Practice
Page 8 · response
Published 14 March 2024

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 scenario-based triage training and schedule recurring biannual sessions, with additional training when needed.

Verbatim wording from the response

“Listening to staff calls on a regular basis and assessing training needs. Following the Coroner's report, we audited a random selection of telephone calls and gave 1:1 feedback (Appendix 7). Scenario-based training on triage protocols to ensure staff are prepared to escalate calls appropriately was undertaken at our training session on 22/4/24, where all non-clinical staff were present. These sessions will be run on a biannual basis (Appendix 4). However, if we need to complete any ad hoc training – based on need, we will. We are also exploring other training offers on this by the ICS and ICB such as training on care navigation and pharmacy first. On Monday mornings which is our busiest times there is a GP at reception to observe and help with queries and navigations.”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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

Establish a comprehensive staff training programme, including provider engagement, identified learning needs and arrangements to release staff for training.

Verbatim wording from the response

“Comprehensive Staff Training Program”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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 Lead GP reception support for staff queries, message-book use and care navigation during busy periods.

Verbatim wording from the response

“GP Observation of Reception Staff: To gain an immediate insight of the current situation, a Lead GP has spent time at reception to help staff with queries and to deal with any concerns regarding the message book. With the Lead GP present, staff have been able to ask questions immediately, provide and receive feedback, and gain confidence in the new procedure. To ensure understanding and compliance with training, we are looking at mechanisms to embed systems and processes for regular review and reporting of monitoring and training.”

Source location

Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024

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

Stop using screen messaging for patient or clinical matters and use the tracked message book or direct clinician communication instead.

Verbatim wording from the response

“Care Navigation and Escalation Training: Staff were instructed to immediately stop using the screen messaging system for patient or any clinical related matters or communication, favouring the message book and/or direct doctor communication. All staff encouraged to seek help and advice if they were concerned about any patient contact. We are currently in discussions with the ICB (Integrated Care Board) and CEPN (Community Education Provider Network) on how we can access this training on a regular basis, not just for our staff but all staff across Barking and Dagenham.”

Source location

Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024

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 a reliable auditable communication system by using EMIS messaging, retaining tracked message-book processes and building an urgent-communication template.

Verbatim wording from the response

“Objective: Implement a robust, failsafe communication system that ensures all patient calls and messages are logged, tracked, and audited effectively.”

Source location

Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024

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

    Share incident learning and escalation improvements through practice and ICB meetings.

    Stated by Church Elm Lane Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  2. 2

    Offer all appointments in the morning and signpost patients to relevant services when practice appointments are unavailable.

    Stated by Church Elm Lane Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
  3. 3

    Implement patient feedback surveys, review feedback themes and establish online channels to improve patient navigation.

    Stated by Church Elm Lane Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 14 March 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Contractual restrictions prevent the practice from closing during core hours to release all staff for training.

    Stated by Church Elm Lane Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Share incident learning and escalation improvements through practice and ICB meetings.

Verbatim wording from the response

“Formal Reviews: The details and lessons from this case were shared in clinical and practice meetings after the incident, running up to the inquest and subsequently on specified dates, focusing on learning from the incident to prevent a future recurrence, training, and next steps. This has been discussed internally in team meetings within the practice and externally with the ICB. The ICB meeting was attended by the Associate Medical Director, ICB Head of Primary Care Barking Place and Borough, and Primary Care Lead for Barking and Dagenham on 17/4/24 (Appendix 6)”

Source location

Response from Church Elm Lane Medical Practice
Page 5 · response
Published 14 March 2024

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

Offer all appointments in the morning and signpost patients to relevant services when practice appointments are unavailable.

Verbatim wording from the response

“Prior to 1/4/24 patients would call or walk in for appointments at 8am and then at 2pm when the afternoon appointments opened. We now offer all the appointments in the morning so that the system is more streamlined and patients for whom we are unable to offer an appointment at the practice, are signposted to relevant services to ensure their needs are met.”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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 patient feedback surveys, review feedback themes and establish online channels to improve patient navigation.

Verbatim wording from the response

“As a team, we have always used patient experiences and feedback to improve our care and will strengthen this engagement by seeking patient opinions. To help our continuous improvement processes.”

Source location

Response from Church Elm Lane Medical Practice
Page 8 · response
Published 14 March 2024

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

Contractual restrictions prevent the practice from closing during core hours to release all staff for training.

Verbatim wording from the response

“Actions: Regular training sessions on effective communication, including handling difficult conversations and demonstrating empathy. We have contacted providers for training and have a list of learning needs. Due to contractual restrictions, practices cannot close during core hours for training. We are in discussions with our colleagues to buddy up with another practice so that all staff can be released for training. We will discuss this and share learning at a PCN level as well. We have already engaged with the ICS and ICB regarding this and are waiting for a response.”

Source location

Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024

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