PFD report

Peter Jeffrey · Prevention of Future Deaths report

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Issued 27 Nov 2013•Eastern District of 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.

View original report
Concerns
3

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of microbiological sampling from open blister wounds
    Part of recurring concern: Failure to obtain clinically indicated microbiological samples
  2. Failure to consider intravenous antibiotics
  3. Failure to consider alternative effective diagnoses or treatments
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The records show no open blister or pus on 17 August 2012, so there was nothing to swab.

    Stated by Guy'S and St Thomas' NHS Foundation TrustDisputes 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

Lack of microbiological sampling from open blister wounds

Wider context from the report

“2. No culture was taken for testing from the open blister which was full of pus. 3. No swab was taken. ”

Is this part of a recurring concern?

Yes — Failure to obtain clinically indicated microbiological samples.

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 consider intravenous antibiotics

Wider context from the report

“4. No intravenous antibiotics were considered. ”

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 consider alternative effective diagnoses or treatments

Wider context from the report

“1. The scans did not reveal DVT and no alternative effective diagnosis or treatment was considered. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 records show no open blister or pus on 17 August 2012, so there was nothing to swab.

Verbatim wording from the response

“Please see above for the primary detail. We agree that in the event of an ‘open blister’ being noted, which included pus or signs of infection, it would be appropriate to expect the necessary organisms to be collected on a swab and then grown and tested in the laboratory.”

Source location

2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
Page 3 · response
Published 22 February 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

If cellulitis persisted, intravenous antibiotics would require referral by the GP to a suitable hospital.

Verbatim wording from the response

“In the event the condition did not resolve after the 2 week course of antibiotics, we agree that IV antibiotics could have been considered, however at this stage Mr Jeffery would have been under the care of his GP, and a referral to a suitable hospital to receive the IV intervention, would have been necessary. Mr Jeffery was not seen at this trust after 17 August 2012.”

Source location

2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
Page 2 · response
Published 22 February 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

No other particular action is intended regarding the diagnostic aspects of this case at this time.

Verbatim wording from the response

“We are not intending to take any other particular action arising from the diagnostic aspects of this case at this time, but remain happy to receive further information from HM Assistant Coroner as to why this is a concern, if this course of action is not considered to be acceptable.”

Source location

2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
Page 3 · response
Published 22 February 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

The Trust’s DVT protocol, diagnostic review, and oral antibiotics were appropriate responses to the working diagnosis of cellulitis.

Verbatim wording from the response

“On the basis of the above information, and despite being aware of the subsequent cause of death 6 months after that intervention, we have been unable to identify what alternative clinical approach might have been adopted for Mr Jeffery in August 2012. The treatment followed the Trust’s DVT protocol, with 2 negative scans followed by referral to medics to review for alternative diagnoses. This took place on 17 August 2012, with a working diagnosis of cellulitis being given, and a 2 week course of antibiotics, which would ordinarily be expected to deliver effective treatment.”

Source location

2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
Page 2 · response
Published 22 February 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.1

  1. 1

    Remind staff to follow through planned referrals and initiate follow-up appointments.

    Stated by Guy'S and St Thomas' NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 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

Remind staff to follow through planned referrals and initiate follow-up appointments.

Verbatim wording from the response

“Whilst not a particular feature of the Regulation 28 report, our own reflection in this case identified that the intended referral to the plastics team – to address the scabbed blister on the sole of Mr Jeffery’s foot - did not occur. We are taking steps to remind staff of the importance of following through such plans, to ensure follow up appointments are put in motion via referrals.”

Source location

2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
Page 3 · response
Published 22 February 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