Recurring concern

Failure to reliably monitor ferritin in patients at risk of iron overload

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First reported 5 Nov 2019•Latest report 28 Feb 2022

Definition

What this concern includes

Includes failures of controls dedicated to monitoring ferritin in patients at risk of iron overload, including defining and communicating checking expectations, arranging or completing measurements, reviewing results and escalating or referring when levels are abnormal; include patients receiving frequent transfusions where ferritin monitoring is clinically indicated.

Not included

  • Excludes general blood-test, medication-monitoring or anaemia-management deficiencies where ferritin monitoring or iron-overload risk is not the shared unsafe condition.
  • Excludes failures to treat iron overload after ferritin has been reliably measured and reviewed.
  • Excludes generic communication, staffing, documentation or funding deficiencies unless they directly impair ferritin monitoring.
  • Excludes monitoring of other laboratory markers or conditions where ferritin and iron-overload risk are not materially involved.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2019–2022

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

East Kent Hospitals University NHS Foundation Trust1
Kent and Canterbury Hospital1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Royal College of Nursing1
Royal College of Pathologists1

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.

  1. Inner North London

    AI-generated summary

    Neil HICKMAN · 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

    Neil Hickman was treated for myelodysplastic syndrome and referred for a stem cell transplant, but died before the transplant could take place from disseminated angio-invasive mycotic infection in the context of immunosuppression and myelodysplasia. The concern was that frequent platelet transfusions at Kent and Canterbury Hospital were not accompanied by ferritin measurements, meaning iron overload might go undetected, although this did not affect the outcome in his case.

    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 measure ferritin levels in patients receiving frequent platelet transfusions

    Wider context from the report

    “Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured. When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient. I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment. ”

    Source location

    Neil HICKMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    Christopher Byron · 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

    Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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 ensure pharmacists and clinical teams apply consistent ferritin-checking expectations

    Wider context from the report

    “2. In addition there was no evidence that on the 30th December or the 9th January 2017 the pharmacist checked Mr Byrons ferritin level. The Court heard from the Clinical lead pharmacist that he would expect this to be done. There was a clear difference between the advice and expectations of the pharmacist and the Clinical team. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026