Recurring concern

Unsafe recognition and management of subarachnoid haemorrhage

First to latest report 26 Nov 2020 — 5 Dec 2025

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 8

What this concern includes

Includes failures of controls specifically dedicated to recognising, investigating, coordinating or treating suspected or confirmed subarachnoid haemorrhage, including acting on clinical information, recognising atypical presentations, imaging and assigning or coordinating responsible specialist care.

What is not included

Excludes generic failures to act on clinical information, review imaging or coordinate specialist care when they are not specifically tied to subarachnoid haemorrhage.
Excludes other intracranial, gastrointestinal, renal or traumatic haemorrhages unless the assertion explicitly concerns subarachnoid haemorrhage.
Excludes generic diagnostic, staffing, training, electronic-record or inter-service coordination deficiencies that are not dedicated to the subarachnoid-haemorrhage pathway.
Excludes broader emergency-department or acute-deterioration failures where subarachnoid haemorrhage is not the named hazard.

Trends

Reports over time

Reports mentioning this concern, 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.

George Eliot Hospital NHS Trust1

Recipient name withheld1

Royal College of Physicians1

Royal College of Radiologists1

Royal College of Surgeons of England1

Warwick Hospital1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

5 Dec2025
Coventry
Concerns raised1
1. Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Royal College of Physicians
Royal College of Radiologists
Royal College of Surgeons of England
Stated actions 2
1. Royal College of Radiologists
  Develop and update professional guidance and standards supporting timely care and clarifying roles and responsibilities in complex multidisciplinary pathways.
2. Royal College of Surgeons of England
  Develop a position statement with SBNS and BNVG recommending how clinical care for subarachnoid haemorrhage patients should be managed.
Respondent positions 5
1. Royal College of Physicians
  The patient did not experience a delay associated with transfer because the treating hospital had a dedicated neurosurgical unit.
  Disputes the concern
1. Royal College of Physicians
  Neurosurgeons and linked multidisciplinary teams are best placed to manage subarachnoid haemorrhage patients and determine treatment.
  Redirects responsibility
2. Royal College of Radiologists
  NHS providers, commissioners and national bodies are responsible for organising, resourcing and operationally delivering emergency and specialist services.
  Redirects responsibility
3. Royal College of Radiologists
  The RCR cannot mandate service reconfiguration or staffing levels, limiting its ability to implement those changes directly.
  Unable to act
4. Royal College of Surgeons of England
  Local multidisciplinary teams may determine how SAH services are delivered, provided neurosurgical and interventional neuroradiology expertise is included.
  Redirects responsibility
AI-generated summary

Man Yin ‘Anita’ Ng · 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

Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.

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
Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages
Wider context from the report
“I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments. There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients. I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care. However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons). I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team. I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies. ”
Source location
Man Yin ‘Anita’ Ng · 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
Develop and update professional guidance and standards supporting timely care and clarifying roles and responsibilities in complex multidisciplinary pathways.

Verbatim wording from the response
“While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.”

Source location
Response from The Royal College of Radiologists
Page 2 · response
Published 15 December 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
Develop a position statement with SBNS and BNVG recommending how clinical care for subarachnoid haemorrhage patients should be managed.

Verbatim wording from the response
“Following this report, the College will work with the SBNS and BNVG to develop a position statement setting out recommendations for the management of the clinical care of SAH patients, and also for the provision of access to the recently published credentialing process for thrombectomy training for non-radiologists, which could allow neurosurgeons with a neurovascular interest to train in both endovascular and open surgical treatment to improve patient-centred decision-making.”

Source location
Response from Royal College of Surgeons
Page 2 · response
Published 15 December 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
The patient did not experience a delay associated with transfer because the treating hospital had a dedicated neurosurgical unit.

Verbatim wording from the response
“The RCP notes the matters of concern raised in this report, particularly the concerns about the processes surrounding the treatment of subarachnoid haemorrhage. Many of those who present with such a clinical problem in the acute hospital setting will be picked up by emergency departments and transferred to the neurosurgeons for further management directly. In this case, Mrs Ng, who presented to a centre with a dedicated neurosurgical unit (at Coventry and Warwickshire hospital), did not have the delay which can be associated with transfer from centres without neurosurgery on site. However, the Royal College of Physicians wish to make clear that in the case where there is no neurosurgical unit, for example, a district general hospitals, pathways should be in place and do exist for transfers to be facilitated as quickly as possible for patients to receive specialist treatment.”

Source location
Response from Royal College of Physicians
Page 1 · response
Published 15 December 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
Neurosurgeons and linked multidisciplinary teams are best placed to manage subarachnoid haemorrhage patients and determine treatment.

Verbatim wording from the response
“In asking for our guidance as to who is best to manage patients with this condition, we would state that the neurosurgeons and linked MDT are best placed to manage these patients, especially due to the fact that not all centres have a dedicated neurosurgical service or neuro-interventional service and the importance of such patients being managed by these specialist teams rather than delay treatment options. This enables appropriate protocols to be in place for the safe and effective use of such services and offers the best outcomes for patients. This said, unfortunately the nature of subarachnoid haemorrhages is such that re-rupture is unpredictable, including primary rupture, and even the best neurosurgeons who manage the complex aneurysms cannot predict whether someone may rupture before intervention can be done in a safe and timely manner.”

Source location
Response from Royal College of Physicians
Page 2 · response
Published 15 December 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
NHS providers, commissioners and national bodies are responsible for organising, resourcing and operationally delivering emergency and specialist services.

Verbatim wording from the response
“The Royal College of Radiologists (RCR) is a charity which works with our members and Fellows to improve medical care across the specialties of Clinical Radiology and Clinical Oncology. The RCR does not commission, fund, manage, or directly deliver clinical services. Responsibility for the organisation, resourcing, and operational delivery of emergency and specialist services lies with NHS providers, commissioners, and national bodies. However, the RCR has an important role in setting professional standards, providing guidance, supporting workforce development, and advocating for system-level change where patient safety and service sustainability are at risk.”

Source location
Response from The Royal College of Radiologists
Page 1 · response
Published 15 December 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
The RCR cannot mandate service reconfiguration or staffing levels, limiting its ability to implement those changes directly.

Verbatim wording from the response
“While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.”

Source location
Response from The Royal College of Radiologists
Page 2 · response
Published 15 December 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
Local multidisciplinary teams may determine how SAH services are delivered, provided neurosurgical and interventional neuroradiology expertise is included.

Verbatim wording from the response
“The College recognises that effective decision-making within the multi-disciplinary team (MDT) is key and that any treatment strategy in patients with aneurysmal subarachnoid haemorrhage should be decided by teams with both surgical and endovascular expertise. The specific details of how this service should be delivered by the MDT may vary and can be decided locally provided there is sufficient input by both neurosurgeons and INR colleagues, leading to safe and effective treatment.”

Source location
Response from Royal College of Surgeons
Page 2 · response
Published 15 December 2025
Open published response
11 Jan2023
Warwickshire
Concerns raised1
1. Lack of awareness of subarachnoid haemorrhage masquerading as migraine and possible neurological findings
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Carol Ann Welch · 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

Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.

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 awareness of subarachnoid haemorrhage masquerading as migraine and possible neurological findings
Wider context from the report
“(1) The subsequent investigation by GEH highlighted two areas which needed addressing: • The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings. This had been done by means of discussions in meetings and a poster displayed in a staff area. • Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department. This had been done by circulating an aide memoire to be given to those in training and existing members of the department. ”
Source location
Carol Ann Welch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Nov2020
Warwickshire
Concerns raised1
1. Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

South Warwickshire University NHS Foundation Trust
Stated actions 6
1. South Warwickshire University NHS Foundation Trust
  Teach junior doctors about subarachnoid haemorrhage and incorporate this case into teaching materials and the junior doctors’ handbook.
2. South Warwickshire University NHS Foundation Trust
  Require junior doctors to reflect on the case, review NICE headache guidance, and discuss learning with educational supervisors through documented appraisal processes.
3. South Warwickshire University NHS Foundation Trust
  Amend the ACP triage form and redesign the AEC MNP GP-referral form to capture GP concerns.
1. South Warwickshire University NHS Foundation Trust
  Review AEC processes to ensure doctors can access and see referral letters before assessing patients.
2. South Warwickshire University NHS Foundation Trust
  Develop and implement an acute headache assessment and management pathway incorporating the Ottawa subarachnoid haemorrhage decision tool.
3. South Warwickshire University NHS Foundation Trust
  Disseminate the revised Acute Headache Pathway across the Trust through the Patient Safety Newsletter and intranet.
AI-generated summary

Eleanor Emily SHERMAN · 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

Eleanor Emily SHERMAN died at Warwick Hospital on 20 August 2020 after collapsing at home; a CT scan confirmed a subarachnoid haemorrhage. The report identified two misdiagnoses, failure to read the GP referral letter, and systemic problems with access to the GP’s electronic records and the scanning of notes.

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 act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan
Wider context from the report
“(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”
Source location
Eleanor Emily SHERMAN · 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
Teach junior doctors about subarachnoid haemorrhage and incorporate this case into teaching materials and the junior doctors’ handbook.

Verbatim wording from the response
“Action ref | Action | Action Lead(s) | Due date | Current status | Done date 10675 | 1. Grant Access to GPs in ED to e-records (Evolve) and Lorenzo - D/W IT, GPs complete e-learning module on e-records (Evolve) and Lorenzo software | ████████ | 01/12/2020 | Completed | 11/01/2021 10676 | 2. Subarachnoid haemorrhage to be discussed as part of the Junior doctors teaching program with this case to be incorporated into Junior doctors teaching and handbook to share learning | ████████ | 31/01/2021 | Completed | 04/11/2020 10678 | 3. Junior doctors to reflect on the case and review NICE guidelines on headache. Junior staff to discuss it with their educational supervisor noting it on their Form R and appraisal. | ████████ | 31/01/2021 | Completed | 25/11/2020 10679 | 4. Learning from incident to be shared with staff working in AEC and ED via team meetings and newsletters.”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 30 December 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
Require junior doctors to reflect on the case, review NICE headache guidance, and discuss learning with educational supervisors through documented appraisal processes.

Verbatim wording from the response
“Action ref | Action | Action Lead(s) | Due date | Current status | Done date 10675 | 1. Grant Access to GPs in ED to e-records (Evolve) and Lorenzo - D/W IT, GPs complete e-learning module on e-records (Evolve) and Lorenzo software | ████████ | 01/12/2020 | Completed | 11/01/2021 10676 | 2. Subarachnoid haemorrhage to be discussed as part of the Junior doctors teaching program with this case to be incorporated into Junior doctors teaching and handbook to share learning | ████████ | 31/01/2021 | Completed | 04/11/2020 10678 | 3. Junior doctors to reflect on the case and review NICE guidelines on headache. Junior staff to discuss it with their educational supervisor noting it on their Form R and appraisal. | ████████ | 31/01/2021 | Completed | 25/11/2020 10679 | 4. Learning from incident to be shared with staff working in AEC and ED via team meetings and newsletters.”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 30 December 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
Amend the ACP triage form and redesign the AEC MNP GP-referral form to capture GP concerns.

Verbatim wording from the response
“| ████████ | 30/11/2020 | Completed | 11/11/2020 10680 | 5. Amendment of the ACP Triage Form to include GP concerns and re-design of the form used by MNPs in AEC to take down GP referrals Consideration to be given to whether this form part of the medical record and to ensure it is included where appropriate. | ████████ | 30/11/2020 | Completed | 13/10/2020 10682 | 6. Review processes within AEC to ensure referral letters are available and seen by Doctors prior to seeing the patient. | ████████ | 30/11/2020 | Completed | 15/10/2020 10681 | 7. Medical team to review processes to ensure improved access to AEC notes for ED staff, including considering real time scanning and making ED aware of AEC note location for re-presenters | ████████ | 31/01/2021 | Completed | 20/11/2020 10683 | 8.”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 30 December 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
Review AEC processes to ensure doctors can access and see referral letters before assessing patients.

Verbatim wording from the response
“| ████████ | 30/11/2020 | Completed | 11/11/2020 10680 | 5. Amendment of the ACP Triage Form to include GP concerns and re-design of the form used by MNPs in AEC to take down GP referrals Consideration to be given to whether this form part of the medical record and to ensure it is included where appropriate. | ████████ | 30/11/2020 | Completed | 13/10/2020 10682 | 6. Review processes within AEC to ensure referral letters are available and seen by Doctors prior to seeing the patient. | ████████ | 30/11/2020 | Completed | 15/10/2020 10681 | 7. Medical team to review processes to ensure improved access to AEC notes for ED staff, including considering real time scanning and making ED aware of AEC note location for re-presenters | ████████ | 31/01/2021 | Completed | 20/11/2020 10683 | 8.”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 30 December 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
Develop and implement an acute headache assessment and management pathway incorporating the Ottawa subarachnoid haemorrhage decision tool.

Verbatim wording from the response
“Awareness raising with ED staff to ensure they are aware that AEC discharge summaries are available immediately after the AEC visit on Lorenzo within the individual patient record (Letters tab on right hand side) | ████████ | 30/11/2020 | Completed | 20/11/2020 10684 | 9. Develop an Acute Headache pathway - ED and Acute Medicine to develop an SOP for the assessment and management of acute severe headache incorporating the Ottawa subarachnoid decision tool. | ████████ | 30/04/2021 | Completed | 03/12/2020”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 30 December 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
Disseminate the revised Acute Headache Pathway across the Trust through the Patient Safety Newsletter and intranet.

Verbatim wording from the response
“In addition to these existing actions, the Working Group felt that there should be a Trust-wide, rather than just ED/AMU, dissemination of the revised Acute Headache Pathway to ensure that the wider Trust clinical body was aware of it. To this end, the Pathway has also not only been disseminated via Acute Medical Admission’s own intranet page, but also introduced via the Trust-wide Patient Safety Newsletter. It is now available for all staff to refer to on the Trust’s intranet site.”

Source location
2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 30 December 2020
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Lack of awareness of subarachnoid haemorrhage masquerading as migraine and possible neurological findings

Concerns raised1

Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Stated actions 2

Respondent positions 5

Stated actions 6