PFD report

Jade Paula REVELL · Prevention of Future Deaths report

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Issued 23 Mar 2023•Derby and Derbyshire

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
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

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

Concerns raised2

  1. Failure of the laboratory-results display to show all results in minimised mode
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable monitoring and follow-up of clinically required laboratory tests
  2. Failure to make abnormal laboratory results prominent in the display
    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.

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

    Reset the results-view scroll bar to the top when selecting another result and release the change to all users.

    Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 24 March 2023.

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

  1. Position

    The system displays scrollbars when information cannot fit on screen, and the table layout used to review results has no issue.

    Stated by The Phoenix Partnership (Leeds) LtdDisputes 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

Failure of the laboratory-results display to show all results in minimised mode

Wider context from the report

“The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results. To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visible – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable monitoring and follow-up of clinically required laboratory tests.

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 abnormal laboratory results prominent in the display

Wider context from the report

“The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results. To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visible – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this. ”

Is this part of a recurring concern?

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

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

Reset the results-view scroll bar to the top when selecting another result and release the change to all users.

Verbatim wording from the response

“As a result of our conversation we were able to identify a change to be made in the system and this was released to all our users on the evening of 13th October 2022.”

Source location

Response from TPP
Page 1 · response
Published 24 March 2023

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 system displays scrollbars when information cannot fit on screen, and the table layout used to review results has no issue.

Verbatim wording from the response

“Figure 3 shows the table layout for reviewing results – where abnormal results are highlighted. There is no issue with this screen.”

Source location

Response from TPP
Page 2 · response
Published 24 March 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