PFD report

Antony Edmund Briggs · Prevention of Future Deaths report

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Issued 28 Feb 2016•Manchester South

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
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 raised2

  1. Failure of Buxton local GPs to act on unavailable urologist information
  2. Failure to make Buxton urology test results viewable at Stepping Hill
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 of Buxton local GPs to act on unavailable urologist information

Wider context from the report

“1. The “system” which operates at Buxton is different from that at Stepping Hill Hospital, and therefore he cannot look at the test results on his screen at Stepping Hill. 2. The urologists see patients at Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton. 3. When the Urologist’s view is not available on screen at Stepping Hill, it should, apparently, fail to the Local GP's in Buxton to act on the information, but they either cannot or do not, thus the patient falls into a lacuna and no action is pursued. This is always of importance, but especially so with a very aggressive malignancy. ”

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 make Buxton urology test results viewable at Stepping Hill

Wider context from the report

“1. The “system” which operates at Buxton is different from that at Stepping Hill Hospital, and therefore he cannot look at the test results on his screen at Stepping Hill. 2. The urologists see patients at Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton. 3. When the Urologist’s view is not available on screen at Stepping Hill, it should, apparently, fail to the Local GP's in Buxton to act on the information, but they either cannot or do not, thus the patient falls into a lacuna and no action is pursued. This is always of importance, but especially so with a very aggressive malignancy. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

Open source report

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

    Strengthen communication between Buxton and Stepping Hill secretarial teams by developing and agreeing a procedure for promptly sharing all Buxton radiology reports.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 January 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The registrar acted appropriately and cannot be criticised for failing to detect the exceptionally rare cancer.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The ultrasound report was not marked urgent because the reported bladder appearance did not create a sufficiently high index of suspicion.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Strengthen communication between Buxton and Stepping Hill secretarial teams by developing and agreeing a procedure for promptly sharing all Buxton radiology reports.

Verbatim wording from the response

“Action We will strengthen communications between the secretarial teams at Stepping Hill and Buxton to ensure that Radiology reports are made available to both sites at the same time. One way of doing this will be to jointly develop and agreed a robust standard operating procedure to ensure that all reports for Radiology activity undertaken at Buxton on behalf of Stepping Hill, regardless of whether or not they are marked urgent, are sent over to the relevant consultant’s secretary at Stepping Hill for the necessary review and action.”

Source location

A-Briggs-Response
Page 2 · response
Published 28 January 2016

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 registrar acted appropriately and cannot be criticised for failing to detect the exceptionally rare cancer.

Verbatim wording from the response

“It is worthy of note at this point that Mr Briggs had an extremely rare form of cancer, an infiltrating adenocarcinoma. One would normally expect to see, if a bladder tumour were present, papillary areas that were very obvious. The Registrar, at his level of experience, acted appropriately and cannot be criticised for not detecting the adeno-carcinoma; indeed it is very possible that a consultant under the same set of circumstances may not have detected it either.”

Source location

A-Briggs-Response
Page 2 · response
Published 28 January 2016

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 ultrasound report was not marked urgent because the reported bladder appearance did not create a sufficiently high index of suspicion.

Verbatim wording from the response

“The ultrasound scan report was not marked ‘urgent’, as the index of suspicion regarding the appearance of the bladder was not high enough for the reporter given that, as mentioned previously, the same appearance could be the result of high pressure chronic retention or chronic cystitis. This, in addition to the ‘time lag’ in getting Mr. Brown’s letter typed into the Advantis system and the fact that the Registrar was not aware of the report contributed to the delay in the diagnosis of Mr Briggs’ adeno-carcinoma.”

Source location

A-Briggs-Response
Page 2 · response
Published 28 January 2016

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