Recurring concern

Unsafe management of upper gastrointestinal bleeding

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First reported 20 Feb 2015•Latest report 18 Dec 2023

Definition

What this concern includes

Includes failures in the dedicated upper-gastrointestinal-bleeding management process, including current and complete guidance, recognition of suspected bleeding or rebleeding, assessment, escalation, urgent endoscopy or surgery, out-of-hours arrangements and related clinical coordination.

Not included

Excludes gastrointestinal bleeding concerns that are not specifically part of the upper-gastrointestinal-bleeding management process.
Excludes generic clinical guidance, staffing, communication or service-capacity deficiencies unless they directly impair management of upper gastrointestinal bleeding.
Excludes diagnostic or treatment failures concerning other gastrointestinal conditions where upper gastrointestinal bleeding is not the material safety concern.
Excludes failures occurring after upper gastrointestinal bleeding has been reliably managed when the remaining issue is unrelated downstream care.

Reports: 4
Individual concerns: 5
Date range: 2015–2023
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1

British Society of Paediatric Gastroenterology, Hepatology and Nutrition1

Calderdale Royal Hospital1

Department of Health and Social Care1

Leeds Teaching Hospitals NHS Trust1

Queen Elizabeth Hospital, Woolwich1

Sheffield Children'S NHS Foundation Trust1

University Hospital of Wales1

Welsh Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Dec2023
North Wales (East and Central)
Concerns raised1
1. Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update the Upper GI Bleeding Management and Principles of Care guideline to align with NICE and British Society of Gastroenterology guidance.
  Stated by Betsi Cadwaladr University LHBStated completed
Respondent positions 1
1. Position
  The upper gastrointestinal bleeding guideline was updated, follows NICE and British Society of Gastroenterology guidance, and is scheduled for review.
  Stated by Betsi Cadwaladr University LHBExisting arrangements considered sufficient
AI-generated summary

Vivienne Greener · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
Wider context from the report
“6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose; ”
Source location
Vivienne Greener · Prevention of Future Deaths report
Page 4 · concerns
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
Update the Upper GI Bleeding Management and Principles of Care guideline to align with NICE and British Society of Gastroenterology guidance.

Verbatim wording from the response
“I can confirm this was updated in July 2023 and will be reviewed again in April 2024. This guideline follows the appropriate NICE guidelines and the acute upper GI bleed care bundle from the British Society of Gastroenterology.”

Source location
Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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 upper gastrointestinal bleeding guideline was updated, follows NICE and British Society of Gastroenterology guidance, and is scheduled for review.

Verbatim wording from the response
“Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose”

Source location
Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 2023
Open published response
7 Feb2020
Inner South London
Concerns raised1
1. Failure to identify risks of gastrointestinal bleeding and reasons for urgent transfer
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Change the consultant’s clinical practice in response to learning from the case.
  Stated by Lewisham and Greenwich NHS TrustStated completed
2. Action
  Share learning with colleagues through a grand round.
  Stated by Lewisham and Greenwich NHS TrustStated completed
3. Action
  Produce and circulate a standard operating procedure for managing suspected upper gastrointestinal bleeding.
  Stated by Lewisham and Greenwich NHS TrustStated completed
AI-generated summary

Mr Adrian Ashford · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Adrian Ashford died in Queen Elizabeth Hospital on 15 December 2018 after a massive upper gastrointestinal bleed, with the medical cause of death recorded as upper gastrointestinal bleeding due to chronic peptic ulcer. Concerns included the absence of a systematic process for recording weights and failures to identify or respond to risks of gastrointestinal bleeding, including consideration of gastroenterology referral.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify risks of gastrointestinal bleeding and reasons for urgent transfer
Wider context from the report
“2. The consultant in acute medicine, who was on call when Mr Ashford was admitted to A&E on 11th December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in A&E on 11th, nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14th he also failed to consider referral to a gastro-enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness. ”
Source location
Mr Adrian Ashford · Prevention of Future Deaths report
Page 1 · concerns
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
Change the consultant’s clinical practice in response to learning from the case.

Verbatim wording from the response
“I have met with the consultant involved and we have discussed this case fully. The consultant has conducted a complete case review and reflection that he will use in his annual appraisal. He has changed his own clinical practice and has also made his colleagues aware through a grand round to share the learning. A new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated.”

Source location
2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
Page 2 · response
Published 18 March 2020
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
Share learning with colleagues through a grand round.

Verbatim wording from the response
“I have met with the consultant involved and we have discussed this case fully. The consultant has conducted a complete case review and reflection that he will use in his annual appraisal. He has changed his own clinical practice and has also made his colleagues aware through a grand round to share the learning. A new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated.”

Source location
2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
Page 2 · response
Published 18 March 2020
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
Produce and circulate a standard operating procedure for managing suspected upper gastrointestinal bleeding.

Verbatim wording from the response
“I have met with the consultant involved and we have discussed this case fully. The consultant has conducted a complete case review and reflection that he will use in his annual appraisal. He has changed his own clinical practice and has also made his colleagues aware through a grand round to share the learning. A new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated.”

Source location
2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
Page 2 · response
Published 18 March 2020
Open published response
23 Mar2016
West Yorkshire (Western)
Concerns raised2
1. Unavailability of urgent or emergency surgery for upper GI bleeds out of hours
2. Lack of protocol guidance for suspected upper GI bleeds in hours
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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 linked to these concerns in the published data.
AI-generated summary

June Elsie Parkes · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of urgent or emergency surgery for upper GI bleeds out of hours
Wider context from the report
“(3) There is presently no provision at Calderdale Royal Hospital to undertake urgent/emergency surgery if deemed necessary, for patients with upper GI bleeds at Calderdale Royal Hospital “out of hours” . The comments made in the final paragraph of B also applies to this point. ”
Source location
June Elsie Parkes · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of protocol guidance for suspected upper GI bleeds in hours
Wider context from the report
“A. The provision and systems in place to identify and undertake urgent or emergency endoscopies at Calderdale royal hospital “in hours” i) From the details set out in section 4, there appears to have been various issues which resulted in a significant length of time elapsing between Mrs Parkes being identified as requiring an urgent endoscopy, and it actually being carried out, which didn’t reflect the timescale recommended within current NICE guidance. ii) The present protocol gives guidance for patients that present with a suspected upper GI bleed out of hours but does not provide guidance for “in hours” iii) the present protocol does not provide guidance to identify a patient who may have suffered a rebleed post endoscopy and what measures should be considered ”
Source location
June Elsie Parkes · Prevention of Future Deaths report
Page 3 · concerns
Open source report
20 Feb2015
West Yorkshire Eastern
Concerns raised1
1. Lack of defined assessment and management steps for variceal bleeding
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share Leeds emergency variceal-management guidelines with referring trusts.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 4
1. Position
  The concerns cannot be pursued personally because involvement would create an obvious competing interest in the index case.
  Stated by Cardiff & Vale University LHBUnable to act
1. Position
  The concerns should be directed to the BSPGHAN President, because they concern complex liver disease and portal hypertension beyond endoscopic banding alone.
  Stated by Cardiff & Vale University LHBRedirects responsibility
2. Position
  Organisations such as RCPCH, JAG, NICE or the NHS are better placed to advance and compel the requested national change.
  Stated by Cardiff & Vale University LHBRedirects responsibility
3. Position
  Current guidelines are considered sufficient for post-operative care and management of bleeding varices, including after prophylactic banding.
  Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

Lexie Louise Harrison · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of defined assessment and management steps for variceal bleeding
Wider context from the report
“(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
Source location
Lexie Louise Harrison · Prevention of Future Deaths report
Page 2 · concerns
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
Share Leeds emergency variceal-management guidelines with referring trusts.

Verbatim wording from the response
“These guidelines are very similar to those used in both London and Birmingham and we have shared the Leeds guidelines with our referring Trusts including Sheffield Children’s Hospital.”

Source location
2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 20 February 2015
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 concerns cannot be pursued personally because involvement would create an obvious competing interest in the index case.

Verbatim wording from the response
“(ii) I have handed over the Chair of the BSPGHAN Endoscopy Working Group (EWG) to a Consultant colleague ████████ who is employed as a Consultant Paediatric Gastroenterologist in the Sheffield Children’s NHS Foundation Trust. Clearly this makes her involvement as the new chair impossible given an obvious competing interest in the index case. Neither should I attempt to take your request forward in a personal capacity.”

Source location
2015-0070-Response-by-University-Hospital-of-Wales
Page 2 · response
Published 20 February 2015
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 concerns should be directed to the BSPGHAN President, because they concern complex liver disease and portal hypertension beyond endoscopic banding alone.

Verbatim wording from the response
“(iii) I think (irrespective of (ii) above) that a matter of this importance would be better directed to the BSPGHAN President rather than the Chair of the EWG. He is copied in to this response and would be pleased to receive your request and then offer a formal reply on behalf of BSPGHAN. The main reason for this is that your concerns are related to the care of children with complex liver disease and the complication of portal hypertension rather than purely the procedure of the endoscopic banding of varices.”

Source location
2015-0070-Response-by-University-Hospital-of-Wales
Page 2 · response
Published 20 February 2015
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
Organisations such as RCPCH, JAG, NICE or the NHS are better placed to advance and compel the requested national change.

Verbatim wording from the response
“(v) Alternatively and / or in addition, you may wish to direct your concerns to organisations within the UK that have more power and influence than our relatively small and poorly resourced society. They would almost certainly come to BSPGHAN for advice / direction but may be better placed to take matters forward and compel the change that you seek. Examples would be the Royal College of Paediatrics and Child Health, JAG, the National Institute for Health and Care Excellence (NICE) or the NHS itself.”

Source location
2015-0070-Response-by-University-Hospital-of-Wales
Page 2 · response
Published 20 February 2015
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
Current guidelines are considered sufficient for post-operative care and management of bleeding varices, including after prophylactic banding.

Verbatim wording from the response
“In relation to parts (e) and (f), post-operative care is the same whether the patient undergoes prophylactic banding or banding after bleeding, and the Leeds team will follow their current guidelines as for management of bleeding varices.”

Source location
2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 3 · response
Published 20 February 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to identify risks of gastrointestinal bleeding and reasons for urgent transfer

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Unavailability of urgent or emergency surgery for upper GI bleeds out of hours

Lack of protocol guidance for suspected upper GI bleeds in hours

Concerns raised1

Lack of defined assessment and management steps for variceal bleeding

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 1

Respondent positions 1

Actions described in response 3

Actions described in response 1

Respondent positions 4