PFD report

Terence COLBY · Prevention of Future Deaths report

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Issued 18 Jun 2025•Suffolk

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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

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Concerns raised1

  1. Failure to undertake vascular examination of a limb when a foot wound and leg pain are reported
    Part of recurring concern: Failure to assess and respond to limb viability concernsPart of recurring concern: Failure to perform clinically indicated physical examinations
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

    Hold a multidisciplinary learning event reviewing peripheral vascular disease, differential diagnosis of foot and lower-limb pain, clinical assessment, red flags and referral criteria.

    Stated by Alexandra & Crestview SurgeriesStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.

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 undertake vascular examination of a limb when a foot wound and leg pain are reported

Wider context from the report

“During the Course of the Inquest evidence was received in the form of a Report from an Expert in General Practice, commissioned by the Court and which considered the care and treatment provided to Mr. COLBY by his GP Practice (Alexandra & Crestview Surgeries, Lowestoft). The Report highlighted substantially sub-standard practice provided to Mr. COLBY on the 17th August 2023 by Alexandra & Crestview Surgeries. This was as follows: On 17th August 2023, despite the presence of a wound on the foot and the report of leg pain, there was a failure by the examining GP to undertake a simple vascular examination of Mr. COLBY’S limb. The Expert Report highlighted that this was despite the fact that “As per the NICE guidance already quoted, peripheral arterial disease needed to be considered here and this was a patient who had attended face to face. In my view this was substantially sub-standard practice and a failure to provide basic medical care (failure to examine) and was against national guidelines.” Although the Inquest did not conclude that the failure identified above was causative of Mr. COLBY’s death, I am concerned that should such practice continue, without remedial action, then there is a risk of future death in other patients. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond to limb viability concerns; Failure to perform clinically indicated physical examinations.

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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

Hold a multidisciplinary learning event reviewing peripheral vascular disease, differential diagnosis of foot and lower-limb pain, clinical assessment, red flags and referral criteria.

Verbatim wording from the response

“Unfortunately, ████████ is no longer member of staff at this surgery. I understand that she is going to give a response on your invitation to do so. However having reviewed the case of Mr Terence Colby, we feel it would be useful to review the presentation of patients with peripheral vascular disease and consider differential diagnosis of ‘foot and lower limb pain’. We are planning on having a learning event when we will discuss the history, presentation, clinical examination, investigation, and referral criteria particularly when there are red flags which become evident.”

Source location

Response from Alexandra & Crestview Surgeries
Page 2 · response
Published 3 July 2025

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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