PFD report

Kathleen Mary GREGORY · 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
5

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 correctly interpret and apply ReSPECT forms during potentially reversible choking events
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.4

  1. Action

    Discuss the analysis findings at the scheduled multidisciplinary meeting and disseminate them to the full practice team.

    Stated by Beccles Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  2. Action

    Conduct a significant event analysis of the case, focusing on RESPECT form completion, wording, detail and content.

    Stated by Beccles Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  3. Action

    Arrange relevant additional RESPECT form completion training for the practice team within four weeks.

    Stated by Beccles Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Once the patient became pulseless and entered cardiac arrest, reversibility had ended and the RESPECT form became relevant.

    Stated by Beccles Medical CentreDisputes 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 to correctly interpret and apply ReSPECT forms during potentially reversible choking events

Wider context from the report

“During the course of the Inquest the Court heard evidence that the paramedic employed by Beccles Medical Centre who attended Mrs. GREGORY on the 29th November 2023 interpreted a Recommended Summary Care Plan for Emergency Care and Treatment (ReSPECT) in place at the time as meaning that resuscitation attempts should not be attempted in circumstances where an un-natural event such as choking was taking place. I am concerned that such an approach does not appear to be consistent with the terms of a ReSPECT Form and its application in circumstances of an event such as choking where an adverse outcome may be reversable. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Discuss the analysis findings at the scheduled multidisciplinary meeting and disseminate them to the full practice team.

Verbatim wording from the response

“1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi-Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025.”

Source location

Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025

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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

Conduct a significant event analysis of the case, focusing on RESPECT form completion, wording, detail and content.

Verbatim wording from the response

“1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi-Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025.”

Source location

Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025

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

Arrange relevant additional RESPECT form completion training for the practice team within four weeks.

Verbatim wording from the response

“2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks.”

Source location

Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025

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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

Review practice-level clinician training on RESPECT form completion and explore further training needs and delivery options.

Verbatim wording from the response

“2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks.”

Source location

Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025

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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

Once the patient became pulseless and entered cardiac arrest, reversibility had ended and the RESPECT form became relevant.

Verbatim wording from the response

“This case, I would agree, shows a reversible cause at the stage at which the patient was choking and had a pulse (was conscious). As per United Kingdom (UK) resuscitation guidance, one would attempt five back-blows followed by five abdominal thrusts (if the initial intervention was ineffective), in order to try and dislodge the obstruction. At the point at which the patient became pulseless/unresponsive (which as noted in the report was the case when the paramedic was notified of the incident) the patient by definition had gone into cardiac arrest and as per UK resuscitation guidelines one would then commence CPR at this point (ALS/backslaps).”

Source location

Response from Beccles Medical Centre
Page 1 · response
Published 5 August 2025

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

Fundamental changes to RESPECT forms or supporting national guidance should be pursued with the relevant national body.

Verbatim wording from the response

“I agree that there is a degree of interpretation with regards to a RESPECT form in such a situation, and that therefore perhaps the wording or structure of the form needs to change. Naturally, this would be an issue for the national issuing body, but if it was felt to be relevant perhaps it is something that could be pursued with them directly.”

Source location

Response from Beccles Medical Centre
Page 1 · response
Published 5 August 2025

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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

    Provide further clinical staff training on managing choking situations on 16 October 2025.

    Stated by Beccles Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.

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

Provide further clinical staff training on managing choking situations on 16 October 2025.

Verbatim wording from the response

“3. Further training for our clinical staff on the management of choking situations, has been arranged for Thursday 16th October 2025.”

Source location

Response from Beccles Medical Centre
Page 2 · response
Published 5 August 2025

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