Terence Colby

ALEXANDRA &  CRESTVIEW SURGERIES

Alexandra Road, Lowestoft, Suffolk NR32 1PL or 141 Crestview Drive, Lowestoft, Suffolk NR32 4TW

Private & Confidential
Suffolk Coroner
Beacon House
White House Road
Ipswich, Suffolk
IP1 5PB

Dear Sir or Madam

17th July 2025

Response to Regulation 28 Report to  prevent future  deaths in relation to Terence Colby (deceased) DoB 08.06.1941,
formerly of 59 Worthing Road, Lowestoft, NR32 4HE.

I would first of all like to say that all involved at the surgery are extremely sorry that this incident has arisen, and we are
aware of the extreme distress and anguish that surrounds such an occurrence for all family and relatives. For this we
wholeheartedly apologise and wish that such an incident could have been avoided. I would like to express my sincere
condolences on behalf of the surgery to all family and relatives.

We understand that the purpose of this enquiry is to see whether we are in a position to ensure that such an incident
doesn’t recur and that any associated learning is shared with all clinicians.

Mr Terence Colby was registered with the surgery since March 1991.

I am 
Terence Colby, he at that time being under the care of 

.

 Senior Partner at Alexandra and Crestview Surgeries. I was not involved in the direct care of Mr

involvement with Mr Colby’s care.

was  formerly  as  salaried  GP  attached  to  this  practice  but  was  a  Locum  at  the  time  of  her

Mr Colby seemed to  have suffered from  pain in his toe  from  mid-May 2023, which was originally treated as being of
musculoskeletal origin, thought to be due to gout. He had seen and reviewed by a number of clinicians including Nurse
Practitioners, Nurses, Doctors and HCA’s during clinical presentation, and with reviewing of photographs that had been
submitted. On the 14"10' August 2023 a review of a photograph that had been submitted to the surgery was interpreted
as  showing  an  infection  of  the  toe.  Antibiotic  was  prescribed  together  with  some  analgesics  (Co-codamol).  The
following day on the 15th0' August 2023 the  wound on his fourth toe, left foot was reviewed by a Healthcare Assistant
who carried out wound care.

On the 17th 01 August 2023, Mr Colby was seen by 
, he having attended the surgery following a call to the 111
service  the  previous  evening when  a  urinary  tract  infection  was  queried. 
noted  that  the  reason  for  the
attendance was frequency of micturition, and she queried as to symptoms that  might be suggestive of a urinary tract
infection. She arranged to test  the  urine which was recorded as being normal. She also  noted that  he had problems
with his left foot with an ulcer on it and this that  this was causing him some pain. She recognised that he was taking
antibiotics and was on analgesics. She safety netted to say that if his urinary symptoms persist, he should return with a
fresh urine sample. She also noted that his foot, although has a painful toe, was being dressed by the Nurse, and he
was having treatment with painkillers and was on antibiotics for a presumed infection. An examination of the foot was
not  undertaken, although 
  did  note  that  there  were  no  calf  symptoms and  no  signs  of  swelling.  This was
presumably in an attempt to rule out a deep vein thrombosis.

 The following day, on the 18,n °' August 2023, the family called as there seemed to be increased “confusion”. Mr Colby
was seen in surgery by 
 who  queried the  presence of  an ischaemic toe, however he notes that the
pulses in the foot were palpable and that there was normal sensation in the foot although there was an ulcer with some
purulent discharge affecting the fourth toe of his left foot. In view of the concern with regardsto the toe being ischaemic
he contacted the Vascular Team and voiced his concerns of the toe being ischaemic. They however felt that it was safe
to  delay  a  review  until the  following week.  Mr  Colby  was  then  admitted  on  the  24th  01 August  2023  and  underwent
thrombolysis, but this was not fully successful. As a consequence, he then underwent a lower limb amputation on the
29th  ot August  2023  but  unfortunately  developed  a  hospital  acquired  pneumonia  and  also  suffered  a  pulmonary
embolism on the 7th °' September 2023. His general health gradually declined, and he was admitted to a hospice and
died on the 27th ol September 2023.

On review of the record and consideration of the expert review of the case as provided in the coroner’s report it would
appear  that  there  were  a  number  of  opportunities  where  Mr  Colby  presentation  could  have  been  reviewed.
Consideration  of  alternative  diagnosis  when  he  presented  with  pain  in  his  foot  could  indeed  have led  to  an  earlier
diagnosis. This may have resulted in an earlier referral to the Vascular Team with the possibility of a greater chance of a
successful outcome. At the time of presentation to 
 she was primarily invited to deal with presumed urinary
symptoms. She noted that he did have problems with his left foot and that this was currently having medical attention
both in terms of dressings and the provision of antibiotics and analgesia.

We feel that the main lesson to learn is to have a holistic approach to the presentation of the patient, so that alternative
management strategies might be employed.

Unfortunately, 
 is no longer a member of staff at this surgery. I understand that she is going to give a response
on your invitation to do so. However having reviewed the case of Mr Terence Colby, we feel it would be useful to review
the presentation of patients with peripheral vascular disease and consider differential diagnosis of ‘foot and lower limb
pain’. We are planning on having a learning event when we will discuss the history, presentation, clinical examination,
investigation, and referral criteria particularly when there are red flags which become evident.

We have weekly clinical meetings when clinical presentations and medical conditions together with new guidance are
discussed in  a multidisciplinary audience  consisting of  GP Partners,  salaried GP’s, GP Registrars, Pharmacy Team,
Nurse Practitioners together with senior administrative staff. A review of the presentation and management of a similar
lower  limb  pain, possible ischaemia will be considered. It  will be  delivered as a group  learning event  to  ensure that
learning is shared with all those present.

This meeting has been arranged and is scheduled to  happen in approximately six weeks’ time. We of course  wish to
ensure that there is no repetition of occurrence of similar problems in the future.

Again, both I and all the Clinicians at the surgery wish to convey our condolences to all the family and relatives of Mr
Terence Colby.

Yours sincerely

Dear HM Area Coroner Stewart OBE

I am writing this letter  in response to the Regulation 28 letter: Report to prevent Future Deaths issued by
the Coroner on 18 June 2025, following the inquest into the death of Mr Terence Colby.

The inquest took place on the 24th of September 2024, the medical cause of death was confirmed as
1a Peripheral vascular disease.

I first became aware of the Regulation 28 letter on 4 August 2025 when I received an email from the
Practice Manager of Alexandra and Crestview Surgery on the 4th of August 2025.

I worked as a locum at Alexandra and Crestview Surgery when I saw Mr Colby on the 17th of August 2023. I
last worked at this Surgery on 1st October 2024.

I understand that an expert in General Practice, commissioned by the court, raised concerns about my
consultation with Mr Colby on the 17th of August 2023 at Alexandra and Crestview Surgery.

I have reflected on my consultation with Mr Colby that I had on the morning of 17th August 2023 and also
extensively reviewed the notes from May 2023 (when he first started coming in to the surgery regarding his
left foot) till September 2023. I first did this in July-August 2024, when I became aware of the expert’s
report. I currently do not work for the surgery and do not have access to the notes.

Below is the factual account of concerns raised from the consultation I had and the events
thereafter,

I had seen Mr Terence Colby, an 82-year-old man with his wife, on the 17thAugust 2023 for the first time,
who had come to see me as per 111 whom he had contacted the previous night. The appointment ledger
notes (triage notes) for me said ‘UTI- spoke to 111 last night, advised to get checked’.
I assessed Mr Colby for urinary symptoms, took a history, checked his urine and gave advice regarding
symptoms not getting better.

I also noted that he had gout in the left foot and currently had developed an ulcer on the toe, which was
being dressed, and that he was put on antibiotics and painkillers (started in the last 2-3 days). Mr Colby
was a non-diabetic, nonsmoker with no previous history of ischemic heart disease or intermittent
claudication.

Mr Colby mentioned some pain in the left ankle and lower leg,  I checked his calf, for any signs of DVT/
cellulitis,  which he had in the past.

When the pain in his toe started to get worse a day after seeing me, he was seen by a colleague  who
assessed and discussed with the vascular team. The vascular team did not think he had any risk factors
for an urgent assessment and agreed to see him the following week.

However Mr Colby went to AE, the same night as the pain got worse.  He was seen by the vascular team
sooner; they diagnosed him as acute on chronic arterial insu(cid:431)iciency. They tried conservative ways to 
saving his leg, but as it failed, he went on to have below knee amputation.
He was doing well but unfortunately, he developed sepsis and was in intensive care. He gradually
deteriorated over the next week and about 4 weeks after his amputation he sadly passed away.

The family questioned if the GP surgery had delayed the diagnosis of Peripheral vascular disease and
hence an inquest was planned.

 I was informed of the Inquest only in July 2024, although Mr Colby had passed away in September 2023.
This was mainly after a report by an expert GP, that they were critical of one consultation the patient had
with me.

There was a pre-inquest hearing in August 2024, I came to know that the Inquest would be a documentary
one on the 24th of September 2024, and no-one will have to attend it.

I extensively reviewed the notes of Mr Colby in July-Aug 2024 to help me understand the events and
reflect on my practice. I discussed the case with my appraiser in Dec 2024.

Mr Colby, who was 82 years old, non-diabetic, nonsmoker, no previous history of coronary artery disease
or intermittent claudication, was seen 7 times between 22/5/23 and 8/8/23 by nurse practitioners, with a
diagnosis of gout in the left 3rd and 4th toe. During this same time he was seen additionally by another
nurse for CKD review and a GP for a fall/ left knee pain who focussed their consultation on what the
patient had  come in to see them for.

On 13/8/23- he contacted NHS 111- who referred him to A and E-James Paget Hospital.
111 notes say, presenting complaint: gout 4th toe left foot, travelling up the leg, change of colour, going to
black.
Gout to 4th toe for months, travelling up the leg, changed colour- going black, in extreme pain. Toe looks
ulcerated, h/o ulcers.
Adv: Ambulance- declined, family will take to ED.

There was a letter from AE saying Mr Colby  did not attend A and E.
However, there is a letter saying that Mr Colby  was assessed by the GP front door at James Paget Hospital
A and E, and the notes say, wound left 4th toe, no injury. On treatment for gout. Lower leg foot very
discoloured/ poor circulation.

14/8/23: urate blood test result: 0.39. (Patient was on allopurinol).
14/8/23 at 18:30: A picture of the toe ulcer that was sent by the patient, was seen by a senior GP at
Alexandra and Crestview Surgery. The note in System One from GP says see photo, infected ulcer, script
issued.
Mr Colby was started on antibiotics (flucloxacillin) and painkillers (co-codamol).

15/8/23, 15:04, Mr Colby was seen by a nurse and the wound was dressed.
Notes say left foot wound, cleaned and covered with soft pore (same as AE dressing), intermittent pain.
He was given a follow up for further dressing the following Monday the 21st august.

17/8/23: NHS111: leg painful, hard red swollen, frequently urinating, confused (being treated for gout,
ulcer on toe, already on antibiotics)
User comments: urinary problems- dysuria, frequency, urgency. No pain, no haematuria, moments of
confusion- wife said normal for him but concerned that it is happening more.
Left leg pain and swelling, pt has gout and an ulcer on leg. c/o worsening pain, leg not hot to touch, soft
around calf, able to weight bear with di(cid:431)iculty.
User comment: leg has some discoloration, di(cid:431)icult to assess as they have said it darkens in the evening 
anyways.
This NHS 111 document says authored on 18/8/23 6:29
It also says encounter time 17/8/23 19:23 to 18/8/23 6:29
Document created 18/8/23 6:29
I am not sure given the timings on this document if this was even completed and scanned before I saw the
patient on the morning of 17th august.

Mr Colby  came to see me on the morning of 17th August 2023 and as the appointment ledger said ‘UTI-

 spoke to 111 last night, advised to get checked’.
I focussed my consultation on the urinary symptoms and checked his urine. I assessed him for what he
came in for, like we generally do in general practice as we have 10 minutes a patient.
I reviewed his notes and made a note that he had gout in his left foot, currently being treated for an
infected ulcer left foot and had a dressing applied. I have made a note of some pains in the left leg and
foot- but no calf swelling (to rule out DVT – which he had in the past).

On reflection, of my consultation on the morning of 17th August 2023 with the benefit of hindsight,

At the time, I did not consider peripheral vascular disease or critical limb ischemia in this patient, the
reasons could possibly be as follows,

1.

There were no risk factors for peripheral vascular disease like diabetes, smoking, history of
coronary artery disease. I don’t remember seeing any mention of current or previous history of
intermittent claudication.

2. On review, there is a possibility of information bias influencing my initial clinical assessment,

since the triage notes on the appointment ledger said, ‘possible UTI, advised to get checked as
per 111’ and the patients primary concern on the day also seemed to be UTI. This alignment may
have reinforced a narrower initial focus on UTI, with less emphasis on concurrent symptoms.

3. Moreover, from the information as noted above of the timings on the documents from NHS 111, I
am not sure if that letter from NHS 111 (about the contact in the early hours of morning 17/8/23),
was scanned onto the patients notes, when he saw me on the morning of 17th August 2023. It
seems likely that the patient, when he booked an appointment for the same morning at the
surgery, verbally told the receptionist that it was about UTI, which she put on the ledger- triage
notes for the doctor. (Often otherwise the receptionist put on something like, ‘see letter from 111
NHS dated so and so’).

4. Also, that a diagnosis of gout was already made by the nurse practitioner whom he had seen

several times over the last 2-3 months. The nurse practitioner had last seen him on the 8th august
2023 and had noted that his symptoms were improved, but that he had a flare.

5.

6.

I would possibly have assumed that the nurse practitioner would have discussed with a GP
colleague or sought advice and guidance from rheumatology regarding the diagnosis as he had
seen the patient multiple times for the same reason. Often at the time of the actual consultation
given the complexity of elderly patients, the time constraints (10 minute slots) especially if
patients are with a family member (who also have information to give, ask questions), presenting
with multiple problems,  it can be very challenging to reconsider established diagnosis that has
been ongoing for few months and noted as getting better.

I always go in early before my clinic starts and review the notes of all patients that are prebooked,
this is mainly to read related background information, letters from hospital, other services and
make rough notes of possibilities, new things to explore with the patient (which might not be on
the patient’s agenda) etc. However, this patient was booked on the same morning after I had
already started my morning clinic. So perhaps I missed the opportunity of scanning the notes in a
bit more depth.

7.

 The patient had been seen by multiple clinicians in the last 2-3 days regarding the new painful
ulcer on the toe that he had developed (including a senior GP partner at the practice who had
seen  a picture of his toe ulcer and also the patient being seen face to face by a clinician at the

 GP front door services at James Paget Hospital specifically for the ulcer and pain) and  he had
been issued antibiotics and painkillers.

8.

The patient, when he came to see me mentioned ‘some’ pains in his lower leg and ankle, after
discussing about the urinary symptoms which seemed to be his main concern. He did not
mention any worsening pains in his toe or any colour changes to me. Very often if some symptom
is bothering a patient or is very important to them, especially if it’s not been sorted after seeing
other clinicians, they often say that first and stress that it is important for them. If it’s not
mentioned, it can be very di(cid:431)icult to assess and explore fully regarding that symptom.

9.

In most patients who have been put on antibiotics by a clinician, especially a senior doctor, we
do wait for 48-72 hrs to assess the e(cid:431)ect unless the patient mentions worsening of symptoms or 
new symptoms of concern.

10. Review of cellulitis history in the past:

Mr Colby had a history of recurrent cellulitis – going back to 2006, often he had multiple
attendances till things settled. In 2015- he was reviewed by the dermatologist- and a letter in
October 2015 from dermatology says diagnosis- bilateral leg oedema with left leg
dermatosclerosis, recurrent cellulitis with persistent athletes’ foot on both sides. When the
patient mentioned that he was getting some pains in the left ankle and lower leg, I thought more
of DVT and cellulitis, (given that he had history of this in the past) rather than peripheral vascular
disease.

In hindsight, I should have taken a deeper history exploring the pain by asking some direct questions,
considered a diagnosis of peripheral vascular disease and performed a simple vascular examination. I
should have documented antibiotic usage and compliance. Exploring the pain might have helped me
assess if I needed to remove the dressing to see the ulcer.

Following this unfortunate incident,

1.
2.

3.
4.

5.

I have reviewed the NICE guidance and CKS NICE on peripheral vascular disease in 2024.
I have made a list of important points below to re-enforce my understanding and learning of
Peripheral arterial disease.
I have discussed the case with my appraiser at my annual appraisal in December 2024.
I have written in my appraisal for December 2024 about the CPD, which I have done from
National library of Medicine/ PubMed, on critical limb ischemia and the important points in
examination of feet in peripheral vascular disease.
I have planned to do a further CPD from BMJ best practice on Peripheral arterial disease in the
coming weeks and note this in my appraisal for December 2025.

6. Following receipt of the Coroners Regulation 28 letter I self-referred myself to the General

Medical Council on 7th of August 2025.

I have learnt a lot from the reading of guidelines/ articles on PubMed regarding peripheral vascular
disease.

The reflection of the case in hindsight, reviewing the sequence of events as to why it happened and what I
could have done to prevent it happening again, has taught me a lot.

 It has changed my practice especially in relation to symptoms in lower limbs and consideration of the
possibility of a diagnosis of peripheral vascular disease.

All this has helped me embed the learning very deeply, I am also planning to do further CPD, by reading
BMJ best practice.

I now consider Peripheral arterial disease/ critical limb ischemia as a di(cid:431)erential diagnosis in all 
patients presenting with pain and ulcer in the lower legs and feet.

I have the following embedded in the back of my mind,

1. On reflection about information bias, made above, highlights the importance of maintaining an

open di(cid:431)erential regardless of the triage wording embedding routine practice of reviewing the 
patient holistically beyond the presenting complaint.

2.

‘Pain in legs especially on leg elevation and easing on hanging them – Arterial insu(cid:431)iciency pain’ 
even if there are no risk factors. Perform simple tests, like checking the colour of the feet,
temperature of the feet, checking for peripheral pulses, doing the Buerger’s test- pallor on
elevation and rubor on hanging them.

3. Explore pain by asking direct questions to get a better understanding of the possible diagnosis.

4.

If something is not fitting in, challenge the diagnosis, think of alternatives.

I have read the NICE guidance on peripheral vascular disease since this incident and have changed
my current practice which is :

1.

2.

3.

4.

5.

I assess people for presence of peripheral arterial disease (PAD) if they have symptoms
suggestive of PAD or history of diabetes, non-healing wounds on legs/ feet or unexplained leg
pain.

If I suspect PAD, I ask for presence and severity of possible symptoms of intermittent
claudication and critical limb ischemia (CLI). Examine legs and feet for CLI for e.g.: leg ulceration,
examine for femoral/ popliteal/ foot pulses and measure Ankle Brachial Pressure Index.

I o(cid:431)er all patients with suspected PAD,  information, advise, support and treatment regarding
secondary prevention of CV disease.

I o(cid:431)er supervised exercise programme to all people with intermittent claudication, when
available - 2 hrs a week over 3-month period, encouraging people to exercise to the point of
maximal pain.

I will assess for Critical limb ischemia: This is characterised by persistent and severe ischemic
rest pain associated with poor tissue perfusion, tissue loss and ulceration.  The preferred option
is to improve tissue perfusion through endovascular or surgical treatment, therefore reducing
pain. In some cases, such treatment is not possible, which can result in continued pain. There is
a 50% mortality rate within a year of diagnosis. These patients tend to be older and have
significant co-morbidities which need to be optimised.

 Pain in CLI is typically worse at night in bed because the limb is elevated, and perfusion does not
have gravity to assist it. This results in sleep deprivation. It is common for these patients to
attempt to sleep with legs hanging out of the bed or preferring to sleep in a chair. Ischemic pain is
described by patients as relentless, unbearable and deep burning pain a(cid:431)ecting all aspects of 
their lives. They are unlikely to pursue with normal activities and may need help with daily tasks.
They often become irritable with strains placed on their relationships.

Patients with CLI require prompt referral to the specialist services for assessment for
revascularisation. Delays in referrals/ treatment can result in poor outcomes including major
amputation.

6. O(cid:431)er paracetamol and either weak or strong opioids depending on the severity of the pain for 

patients with CLI.

As a GP professional I have always held high standard of care for my patients despite the current
challenges. I regularly attend CPD events on weekday evenings and weekends on various topics in
general practice to keep up with new information and guidance. As a GP, in the current scene, it is more
and more noticeable that the consultations are getting ever so complex, with lack of resources, limited
appointment time, extremely long waiting lists to see the specialists/ long queues at A and E, advancing
age of the population with multiple co-morbidity and polypharmacy, driving higher demand for holistic
person centred care that addresses complex physical, psychological and social care at primary care
level.

I have been deeply saddened by this case. It has highlighted that there were so many learnings from the
missed opportunities to address the root cause of concern through the patient’s journey. I have learnt a
lot from it, on reflection and reading various guidelines. I will continue to stay updated reinforcing my
knowledge and learning.

Please let me know if you require any further information

Yours sincerely

03/09/2025