PFD report

Helen COOGAN · Prevention of Future Deaths report

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Issued 4 May 2023•Inner North 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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised1

  1. Failure to obtain qFIT test results
    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.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    No further action could be added because the patient had to collect and provide the sample required for qFIT testing.

    Stated by Ritchie Street Group PracticeNo action considered necessaryThe respondent said that 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 obtain qFIT test results

Wider context from the report

“You provided a statement regarding the care given to Ms Coogan by you and your colleagues at the Ritchie Street Group Practice. In it, you said that she reported to Dr ████████ in July 2022 that she had had abdominal cramps present for months, with alternating loose stool and constipation. You said that a qFIT tool test for blood was requested but there was no subsequent result. You said the same about the qFIT requested on 13 September 2022. It was not clear to me why there were no qFIT results but, given the cause of Ms Coogan’s death, that seems to me to be a matter worthy of your investigation, particularly in case there is some system issue. ”

Is this part of a recurring concern?

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

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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

No further action could be added because the patient had to collect and provide the sample required for qFIT testing.

Verbatim wording from the response

“Plan - discussed it at a partners meeting – nil further could be added - raised a significant event to discuss with the wider team to see if anything can be learned and improved from this – nil further could be added”

Source location

Response from Ritchie Street Group Practice
Page 1 · response
Published 22 June 2023

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.2

  1. 1

    Discuss the case at a partners meeting to identify any further actions.

    Stated by Ritchie Street Group PracticeStated completedThe respondent said that this action was complete when they made their response on 22 June 2023.
  2. 2

    Raise a significant event for wider team discussion and learning to identify improvements.

    Stated by Ritchie Street Group PracticeStated completedThe respondent said that this action was complete when they made their response on 22 June 2023.

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

Discuss the case at a partners meeting to identify any further actions.

Verbatim wording from the response

“Plan - discussed it at a partners meeting – nil further could be added - raised a significant event to discuss with the wider team to see if anything can be learned and improved from this – nil further could be added”

Source location

Response from Ritchie Street Group Practice
Page 1 · response
Published 22 June 2023

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

Raise a significant event for wider team discussion and learning to identify improvements.

Verbatim wording from the response

“Plan - discussed it at a partners meeting – nil further could be added - raised a significant event to discuss with the wider team to see if anything can be learned and improved from this – nil further could be added”

Source location

Response from Ritchie Street Group Practice
Page 1 · response
Published 22 June 2023

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