Recurring concern

Incomplete cardiovascular risk information for clinical assessment and investigation

First to latest report 25 Feb 2014 — 6 Jun 2025

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
6

What this concern includes

Includes failures to obtain, record, present or use clinically relevant cardiovascular risk information, including family history, cholesterol or HbA1c results and comparable risk factors, where the information is needed to guide cardiovascular assessment, investigation or safety-related fitness decisions.

What is not included
  • Excludes general clinical-history, documentation or information-sharing failures where cardiovascular risk information is not the material object.
  • Excludes failures involving cardiovascular treatment, monitoring or follow-up after the relevant risk information was reliably available.
  • Excludes non-cardiovascular risk factors and unrelated diagnostic or fitness-assessment information.
  • Excludes generic risk-assessment deficiencies that do not specifically concern incomplete cardiovascular risk information.

Reports and published responses 4 reports

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

  1. Manchester South

    AI-generated summary

    Esme Vera Louise Atkinson · 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

    Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

    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 of routine echocardiogram protocols to account for relevant genetic heart-defect history

    Wider context from the report

    “5. In Esme’s case although her mum’s identical twin had a heart defect this did not in the North West, trigger the protocol for a routine echocardiogram. A heart defect in her mother would have. It was unclear why this was excluded given the genetic link. ”

    Source location

    Esme Vera Louise Atkinson · 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

    Use the updated NIPE handbook to support improved congenital heart disease screening practice, including risk factors, examination and result management.

    Verbatim wording from the response

    “Postnatally, the NIPE recommends the offer of screening to all babies born in England for conditions relating to the eyes, heart, hips and testes (if applicable).”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 18 June 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

    Whether additional fetal echocardiography is offered depends on individual risk assessment and the treating clinician’s discretion.

    Verbatim wording from the response

    “You raised specific concerns that there is no routine echocardiogram of babies born to a mother with diabetes and that in Esme’s case, although her mum’s identical twin had a heart defect, this did not trigger the protocol for a routine echocardiogram. NHS England encourages all trusts to follow the FASP criteria for offering screening for fetal anomalies. Additional screening for fetal anomalies may include a fetal medicine scan and/or a fetal echocardiogram for patients at higher risk of fetal anomalies for such as maternal diabetes, or having a first degree relative with a congenital heart disease (for example an affected parent or sibling). We agree that additional screening for Esme would have been a reasonable course of action, given the increased risk associated with a genetically identical maternal aunt with a heart defect.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 18 June 2025

    Open published response

  2. Berkshire

    AI-generated summary

    James Ferris Baxter · 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

    James Ferris Baxter, a passenger-carrying coach driver, died at Junction 15 of the M25 while driving a coach with 25 passengers on board after suffering an acute right coronary artery thrombosis. The coach crashed but was brought to a stop by a passenger, causing minor injuries and vehicle damage. Concerns included the renewal and medical assessment process for his Category D licence, and whether risk-based cardiovascular assessment and relevant diabetes and cholesterol information should be incorporated into driver licensing assessments.

    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 provision on Form D4 for recent HbA1c and cholesterol results

    Wider context from the report

    “4) I received evidence that DVLA does commission functional cardiac stress testing for those with known cardiovascular disease, or those with symptoms suspected to be related to cardiac disease but this arises only in cases where such conditions are declared. Apparently there is no mechanism in place to diagnose asymptomatic individuals with these tests, but the evidence in the investigation indicated that a risk-based stratification system (for example a Q-Risk score) which takes account of age and comorbidities, rather than just cardiac symptoms, was feasible to reduce the risk of incidents of this type, thereby prompting consideration of stress testing. Alternatively a periodic stress test related to age was suggested as a means of ameliorating risk. Evidence was also provided indicating that on the D4 form there should be a provision to fill in HbA1c and cholesterol results produced within the previous 3 months as obtained by the applicant from a GP. ”

    Source location

    James Ferris Baxter · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 DVLA can act only on information received from licence holders or healthcare professionals about known medical conditions.

    Verbatim wording from the response

    “I have noted your suggestions regarding the possibility of adding Hbac1 and cholesterol readings as standard to the D4 forms, as a way of screening for risk of heart-related conditions. Currently, the DVLA can only act on information received from licence holders and/or healthcare professionals about known medical conditions.”

    Source location

    2024-0194 Response from Department for Transport
    Page 3 · response
    Published 29 April 2024

    Open published response

  3. Inner North London

    AI-generated summary

    Trevor Coy BAILEY · 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

    Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate 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 record relevant family medical history

    Wider context from the report

    “1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”

    Source location

    Trevor Coy BAILEY · Prevention of Future Deaths report
    Page 2 · 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

    Failure to elicit relevant family medical history

    Wider context from the report

    “1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012. However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████ ████████, on 19 or 27 April 2023. The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient. ”

    Source location

    Trevor Coy BAILEY · 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

    Update the NHS health-check template to record negative family history of ischaemic heart disease.

    Verbatim wording from the response

    “We have taken the following steps to update the family history of coronary heart disease (IHD).”

    Source location

    Response from Chuch Lane Surgery
    Page 2 · response
    Published 6 November 2023

    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

    Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.

    Verbatim wording from the response

    “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

    Source location

    Response from Chuch Lane Surgery
    Page 3 · response
    Published 6 November 2023

    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

    Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.

    Verbatim wording from the response

    “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

    Source location

    Response from Chuch Lane Surgery
    Page 3 · response
    Published 6 November 2023

    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

    Train staff to collect and accurately record family-history information in the clinical system.

    Verbatim wording from the response

    “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

    Source location

    Response from Chuch Lane Surgery
    Page 3 · response
    Published 6 November 2023

    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

    Audit new family-history entries every 12 months to assess system progress.

    Verbatim wording from the response

    “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.”

    Source location

    Response from Chuch Lane Surgery
    Page 3 · response
    Published 6 November 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 family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.

    Verbatim wording from the response

    “It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.”

    Source location

    Response from Chuch Lane Surgery
    Page 2 · response
    Published 6 November 2023

    Open published response

  4. Manchester West

    AI-generated summary

    Lee Terence Curran · 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

    Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.

    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 take full account of family history when clinically investigating prisoners with possible high cholesterol

    Wider context from the report

    “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows: a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”. b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.” Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol. Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time. ”

    Source location

    Lee Terence Curran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026