Recurring concern

Unreliable recognition and assessment of anaemia

First to latest report 5 Nov 2019 — 16 Sep 2021

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
4

What this concern includes

Includes failures of controls specifically dedicated to recognising or assessing anaemia, including sufficient clinical consultation, consideration of relevant anaemia or transfusion history, diagnostic testing such as ferritin, and appropriate initial triage or referral decisions.

What is not included
  • Excludes generic shortages, reduced access or consultation-capacity concerns unless they directly impair recognition or assessment of anaemia.
  • Excludes nutritional, socioeconomic or pandemic-related causes of anaemia unless the report identifies a deficient anaemia-recognition or assessment control.
  • Excludes treatment, prescribing or follow-up failures occurring after anaemia has been adequately recognised and assessed.
  • Excludes failures concerning unrelated conditions or diagnostic processes without a specific anaemia connection.

Reports and published responses 3 reports

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

  1. West Yorkshire (Western)

    AI-generated summary

    Maya ZAB · 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

    Maya Zab died from multi-organ failure associated with chronic severe microcytic hypochromic anaemia and severe iron deficiency on 6 August 2020. The report raised concerns about increased severe nutritional anaemia and deaths among children in the Yorkshire & Humber region during 2020, with possible indirect effects of the pandemic including fewer consultations, reduced social contact, and widening socioeconomic inequalities.

    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

    Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children

    Wider context from the report

    “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings: • The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia • Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health • Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern ”

    Source location

    Maya ZAB · 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

    Restore NHS services following pandemic disruption.

    Verbatim wording from the response

    “Whilst contact with the NHS was reduced during the pandemic, there was also a clear narrative that the NHS remains open for patients who need care, and this remains the message. NHSEI is working hard to restore services across the country.”

    Source location

    2021-0316-Response-from-NHS-England_Published
    Page 2 · response
    Published 23 September 2021

    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

    Repatriate redeployed public health nurses to health visiting services.

    Verbatim wording from the response

    “We recognise the impact the pandemic has had on the delivery of health visiting services. With the onset of COVID-19, some public health nurses were redeployed, however I can confirm that they were all repatriated by the end of July 2020.”

    Source location

    2021-0316-Response-from-NHS-England_Published
    Page 2 · response
    Published 23 September 2021

    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

    Advise services not to redeploy professionals supporting children and families, and support provision to vulnerable families.

    Verbatim wording from the response

    “In response to Winter Planning in 2020, Public Health England and NHSEI Chief Nurses, together with the Local Government Association, wrote to Directors of Nursing across the country to advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs, should not be redeployed to other services and should be supported to provide services through pregnancy, early years and to the most vulnerable families. (Joint letter on Winter Planning: Support to Children and Families, 7 October 2020 | Local Government Association.)”

    Source location

    2021-0316-Response-from-NHS-England_Published
    Page 2 · response
    Published 23 September 2021

    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

    Publish an updated health visiting and school nursing delivery model with commissioning guidance.

    Verbatim wording from the response

    “Further an updated health visiting and school nurse service delivery model, together with commissioning guidance, was also published in March 2021. (Health visiting and school nursing service delivery model - GOV.UK (www.gov.uk).)”

    Source location

    2021-0316-Response-from-NHS-England_Published
    Page 2 · response
    Published 23 September 2021

    Open published response

  2. Cumbria

    AI-generated summary

    Patricia Ann Douglas · 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

    Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

    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 initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history

    Wider context from the report

    “(1) The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to the Covid service and does not seem to have given weight to the history of anaemia and transfusion. Could the pathway be improved to give better guidance to call handlers? ”

    Source location

    Patricia Ann Douglas · Prevention of Future Deaths report
    Page 1 · 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

    Using either COVID-19 or the pre-pandemic breathlessness pathway would have produced the same outcome: clinical assessment within one hour.

    Verbatim wording from the response

    “At the time of the call, due to the increased pressures on NHS 111 services nationally arising from the COVID-19 pandemic, those patients with symptoms of breathlessness that did not require an ambulance response or referral to an Emergency Department / Urgent Treatment Centre were referred to the COVID Clinical Assessment Service. A clinician would then assess the patient, in this case within a one-hour timeframe, considering potential causes of breathlessness (COVID-19 or otherwise) and other relevant factors such as medical history in order to make an appropriate management plan.”

    Source location

    2020-0286-Response-from-NHS-Digital-Redacted
    Page 2 · response
    Published 7 January 2021

    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

    Non-clinical health advisors should not exercise clinical discretion; recorded medical history is shared with clinicians for subsequent assessment and decision-making.

    Verbatim wording from the response

    “Where information such as past medical history is declared by the patient, the health advisor is able to document this within NHS Pathways. However, it would not be deemed clinically appropriate for non-clinically trained health advisors to use discretion or make judgements in respect of any medical history described. Instead, where additional medical information is deemed by the health advisor may exit the system at an earlier stage in order to refer the patient for additional clinical assessment within an appropriate timeframe. Any medical information recorded is shared with the receiving clinician to inform their subsequent assessment and decision-making.”

    Source location

    2020-0286-Response-from-NHS-Digital-Redacted
    Page 2 · response
    Published 7 January 2021

    Open published response

  3. 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 obtain ferritin levels for anaemia management

    Wider context from the report

    “1. In this case the Trust Guideline ‘Patient Blood Management of Medical Patients’ sets out the Pathway for the Management of Anaemia. In addition to this Trust documents there is NICE guidance for Anaemia – iron deficiency (revised 2018). Both of these documents include as a key factor the obtaining of ferritin levels, albeit the question as to the interpretation of such results will be dependant on the patients presenting condition. On the 30th December 2016 no sample was taken to check the ferritin levels. ”

    Source location

    Christopher Byron · 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.

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Data last updated 7 September 2026