25 Jun 2026 KERRY TERESA SINGH · Prevention of Future Deaths report City of London
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Concerns raised 1
Lack of a system for checking access to and reading of important test results View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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KERRY TERESA SINGH · 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
Kerry Teresa Singh died on 14 July 2025 after urgent extraction of a failing pacemaker lead caused a tear to the superior vena cava, severe bleeding and unsuccessful resuscitation. The report identified delays in involving a tertiary centre, failures to review a critical test result and complete a referral, inadequate systems for patient involvement and task monitoring, and a lack of internal investigation or review.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a system for checking access to and reading of important test results
Wider context from the report “5. The Deceased’s critical test result, which was available from the 31st December 2024, was not accessed by the responsible consultant until March 2025. Further, the decision made subsequently, on the 3rd April 2025, to refer for lead extraction was not acted upon and no referral was made. It is not appropriate for concerns about the clinician to be addressed by means of this PFD Report. However, the failures raise concern also for the systems in place in the William Harvey Hospital. First, in evidence, the clinician suggested that she had not been provided by the Trust with sufficient time in which to perform these tasks and that she was overwhelmed by receiving an unnecessary number of communications. Secondly, I was told that there was no system in place to check that test results have been accessed and read or to alert clinicians to test results which had not been accessed and read , whether through IT alerts or otherwise. Thirdly, it seems that there is no system in place to check that important tasks (such as making a patient referral) have been performed and/or to identify when they have not been performed within a reasonable period.
” Source location KERRY TERESA SINGH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the abnormal-results process to categorise urgency, specify response routes and timeframes, escalate unacknowledged findings, and document communication and clinical action.
Verbatim wording from the response “The Trust recognises that the reliable management of abnormal results and important clinical actions requires a closed-loop process. Simply sending a result or communication to a named clinician does not, by itself, provide assurance that the information has been reviewed, acknowledged and acted upon.” Source location Response from East Kent Hospitals University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Verbatim wording from the response “Actions agreed through the Devices MDT are now recorded on a central action log, with a named responsible individual and target completion date. Outstanding or overdue actions are reviewed through the MDT process and escalated where necessary. This includes tertiary-centre referrals, investigations, consultant review, changes to follow-up and communication with patients. Where tertiary referral is agreed, completion is confirmed by evidence that the referral has been submitted and recorded.” Source location Response from East Kent Hospitals University NHS Foundation Trust
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12 Jun 2026 Suzanne FREDERICKS · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results View source
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Suzanne FREDERICKS · 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
Suzanne FREDERICKS, who had previously undergone a liver transplant, was admitted to Colchester General Hospital with liver and kidney problems and died there on 4 November 2024 after treatment was unsuccessful. The principal concern was whether clinicians caring for transplant patients in non-specialist hospitals could obtain sufficiently up-to-date blood test results, as delays in processing laboratory results might affect treatment and survival.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results
Wider context from the report “There is a concern as to how clinicians caring for transplant patients in non-specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results . Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved .
” Source location Suzanne FREDERICKS · Prevention of Future Deaths report
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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 Standardise transplant blood-sample routing through a single contact offering daily tacrolimus assays and sample prioritisation on request.
Verbatim wording from the response “The Trust has however taken the decision to standardise the practice and send all blood samples to a single point of contact that has a daily assay for tacrolimus and can prioritise a sample on request.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for assuring tacrolimus sample testing and reporting rests with the General Hospital and testing laboratory.
Verbatim wording from the response “The evidence before the inquest indicated that the General Hospital received tacrolimus results on more occasions than the single occasion on which CUH was involved. It therefore appears that the samples were being sent to another organisation for testing during the relevant period, which is ultimately a matter for the General Hospital and the testing laboratory to assure you accordingly.” Source location Response from Cambridge University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CUH cannot require the General Hospital to send tacrolimus samples exclusively to CUH laboratories.
Verbatim wording from the response “Furthermore, CUH does not have the power to compel the General Hospital to send its samples to CUH laboratories to the exclusion of all others.” Source location Response from Cambridge University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delayed or intermittent tacrolimus results are outside CUH’s direct control, so CUH is not the appropriate organisation to address the identified risk.
Verbatim wording from the response “For these reasons, the identified concern regarding delayed and/or intermittent tacrolimus results is not within CUH's direct control. CUH is therefore not able to ameliorate the risk of death identified in this case. However, CUH recognises the importance of timely tacrolimus monitoring and remains willing to support any wider regional or national work to improve pathways for transplant patients receiving care outside specialist centres.” Source location Response from Cambridge University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The renal unit cannot process specialist transplant tests, so samples must be sent elsewhere for processing and results.
Verbatim wording from the response “The Renal Unit at Colchester General Hospital are able to process most blood samples for transplant patients but at present are not able to process specialist tests, such as tacrolimus concentration. Colchester General Hospital therefore have to obtain blood samples for such tests and send them to a transplant centre to process and return results.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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10 Jun 2026 Judith Marsland · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to review, act on, and escalate abnormal blood results View source
This report raised 2 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.
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Judith Marsland · 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
Mrs. Marsland died in hospital on 14 November 2025 after a urinary infection progressed to sepsis, septic shock and multiorgan failure. The principal concerns were that abnormal blood results were not reviewed or escalated, she was discharged without antibiotics, and key action-plan measures for structured handover and named clinical responsibility had not been implemented.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review, act on, and escalate abnormal blood results
Wider context from the report “3) I heard evidence from ████████, the lead investigator from the Trust PSII that Mrs. Marsland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7ᵗʰ November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home.
” Source location Judith Marsland · Prevention of Future Deaths report
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8 Jun 2026 Barbara Joan COPE · Prevention of Future Deaths report South Yorkshire (West)
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Concerns raised 2
Failure to communicate and follow up abnormal blood results View source Failure to review and act on clinical records and recent investigation results View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
the Rotherham NHS Foundation Trust
Flag all abnormal results within MEDITECH.
View source
the Rotherham NHS Foundation Trust
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
View source
the Rotherham NHS Foundation Trust
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
View source
the Rotherham NHS Foundation Trust
Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
View source
the Rotherham NHS Foundation Trust
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
View source
the Rotherham NHS Foundation Trust
Develop a Power BI module to monitor acknowledgement of results.
View source
the Rotherham NHS Foundation Trust
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
View source
the Rotherham NHS Foundation Trust
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
View source See 5 more actions
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Barbara Joan COPE · 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
Barbara Joan COPE, a 75-year-old woman, presented to Rotherham Hospital with decreased conscious levels, slurred speech and reduced oral intake, and was later found to have a high paracetamol level. The result was not reviewed or acted upon for approximately 19 hours, delaying time-critical treatment. The principal concerns were failures in communicating and following up abnormal results, reviewing investigations during clinical deterioration, and clearly assigning responsibility for ongoing care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate and follow up abnormal blood results
Wider context from the report “(1) Although a blood sample was collected and tested in a timely manner, there was no evidence of communication and/or follow up of the abnormal result , therefore time critical medication was not commenced until 19 hours later.
” Source location Barbara Joan COPE · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review and act on clinical records and recent investigation results
Wider context from the report “(2) Even when the patient clinically deteriorated overnight and required two separate clinical reviews, the blood results were not reviewed and/or acted upon . If clinical records and recent investigations results are not reviewed then appropriate medical management will be delayed or will not occur.
” Source location Barbara Joan COPE · Prevention of Future Deaths report
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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 Flag all abnormal results within MEDITECH.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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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 Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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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 and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Verbatim wording from the response “Since Mrs Cope’s death we have reviewed and updated the Standard Operating Procedure for the Management of Critically Abnormal Pathology Results in Clinical Areas and I attach a copy of the same for your reference.” Source location Response from Rotherham District General Hospitals
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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 Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
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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 Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
Open published response
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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 Power BI module to monitor acknowledgement of results.
Verbatim wording from the response “In addition, the Trust has developed a Power BI module to monitor acknowledgement of results which continues to show an improvement in clinicians’ responsiveness to the management of test results.” Source location Response from Rotherham District General Hospitals
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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 Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Verbatim wording from the response “I was concerned to hear that Mrs Cope deteriorated overnight, requiring two separate clinical reviews and despite this, her blood results were not reviewed. The Trust has a clear handover process in place whereby medical staff working in hours, handover tasks for follow up to the out of hours team at the face-to-face handover meetings. In addition to this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the use of the ‘alertive bleep’ system which flags critical blood results on the bleep system.” Source location Response from Rotherham District General Hospitals
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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 Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Verbatim wording from the response “The Deputy Chief Nurse in conjunction with colleagues from the learning from deaths programme, clinical effectiveness team and the quality governance team will include the learning from this incident in the Quality Newsletter focusing on the importance of acting upon time critical blood results.” Source location Response from Rotherham District General Hospitals
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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 Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
Verbatim wording from the response “I was concerned to hear that Mrs Cope deteriorated overnight, requiring two separate clinical reviews and despite this, her blood results were not reviewed. The Trust has a clear handover process in place whereby medical staff working in hours, handover tasks for follow up to the out of hours team at the face-to-face handover meetings. In addition to this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the use of the ‘alertive bleep’ system which flags critical blood results on the bleep system.” Source location Response from Rotherham District General Hospitals
Open published response
Concerns raised 1
Failure of policies, systems and electronic records to proactively drive infection testing and follow-up View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mrs Mary (also known as Moira) Forlin · 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
Mrs Mary Forlin was admitted to hospital after a fall at home with a long lie and was suffering from respiratory failure, likely driven by an infection of unknown source. She later collapsed and died from multiorgan failure arising from the infection and respiratory failure. The principal concerns were that clinicians did not actively follow guidance to review antibiotic treatment, microbiological testing was not undertaken early, and policies, systems and electronic records did not provide proactive checks or alerts to support infection testing, treatment and review when treatment was ineffective.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of policies, systems and electronic records to proactively drive infection testing and follow-up
Wider context from the report “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.
Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests , including whether and when results have been obtained, or whether further specialist tests should then be required , enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.
Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working.
” Source location Mrs Mary (also known as Moira) Forlin · Prevention of Future Deaths report
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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 clinical decision support within phase three of the electronic patient record implementation.
Verbatim wording from the response “Delivering the greatest benefits with clinical decision support (CDS) requires mature data, careful design and collaboration between digital teams and clinicians. Clinical decision support is included in phase 3 of our EPR implementation.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
10 Mar 2026 Jennine Sasha Romeo · Prevention of Future Deaths report City of London
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Concerns raised 2
Lack of a system ensuring timely review and consideration of echocardiography results View source Lack of a pathway for echocardiography teams to flag results to clinical teams View source
Linked response
North Middlesex University Hospital
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
North Middlesex University Hospital
Operate and update the echocardiography escalation protocol, including senior review routes and a new criterion for pulmonary hypertension findings.
View source
North Middlesex University Hospital
Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations for senior clinical review.
View source
North Middlesex University Hospital
Operate and annually review the echocardiography escalation pathway, including escalation of significant abnormalities and the added criterion for new pulmonary hypertension.
View source
North Middlesex University Hospital
Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations to the Cardiology service manager for senior review.
View source See 1 more action
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Jennine Sasha Romeo · 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
Jennine Sasha Romeo died on 29 May 2025 after developing multiorgan failure following complications of mitral valve surgery and subsequent re-do surgery. The January 2025 echocardiogram showing serious cardiac abnormalities was not clinically reviewed until May, after hospital outpatient appointments had been cancelled. The report identified concerns about the absence of systems to ensure timely review of results and a pathway for the echocardiography team to flag significant findings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a system ensuring timely review and consideration of echocardiography results
Wider context from the report “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital.
There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned.
Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team.
” Source location Jennine Sasha Romeo · Prevention of Future Deaths report
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 a pathway for echocardiography teams to flag results to clinical teams
Wider context from the report “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital.
There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned.
Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team.
” Source location Jennine Sasha Romeo · Prevention of Future Deaths report
Open source report
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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 Operate and update the echocardiography escalation protocol, including senior review routes and a new criterion for pulmonary hypertension findings.
Verbatim wording from the response “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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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 Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations for senior clinical review.
Verbatim wording from the response “Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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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 Operate and annually review the echocardiography escalation pathway, including escalation of significant abnormalities and the added criterion for new pulmonary hypertension.
Verbatim wording from the response “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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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 Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations to the Cardiology service manager for senior review.
Verbatim wording from the response “Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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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 An established echocardiography escalation pathway and protocol adequately address significant abnormal findings.
Verbatim wording from the response “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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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 An established echocardiography escalation pathway and protocol are considered sufficient to address significant abnormal findings.
Verbatim wording from the response “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
4 Mar 2026 Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Delays in official radiologist reporting of chest X-rays showing cardiomegaly View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Viviana-Ray Winnie Elsie Wendy Butnaru · 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
Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in official radiologist reporting of chest X-rays showing cardiomegaly
Wider context from the report “(3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later .
” Source location Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report
Open source report
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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 Complete and formalise the radiology policy review to document how clinical teams can expedite imaging reports for clinical concerns.
Verbatim wording from the response “The Radiology Department identified that guidance for clinical teams on how to expedite an imaging report due to clinical concern was not documented in Trust radiology policies and procedures. As such, the Director of Nursing has confirmed that a review of the Trust’s policy, Guide for making the best use of a Radiology Department (MSEGL23134) will be completed by 1 June 2026 to ensure an updated version is formalised to include this guidance going forward. The Trust will be able to share a copy of this updated policy with you in due course if it is of assistance.” Source location Response from Mid and South Essex NHS Foundation Trust
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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 the updated radiology escalation guidance with paediatric teams and publish it on the Trust intranet.
Verbatim wording from the response “As a result of these guideline changes, targeted sharing of the changes will be undertaken with the Paediatric teams across our sites within MSEFT, alongside the updated guideline being available on the Trust's intranet page, which is accessible for all staff.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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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 Formal chest X-ray reporting delays lie outside the respondent’s control.
Verbatim wording from the response “• Chest X ray reporting. This lies outside of our control but we recognise that there is often some delay between images being taken in the context of an emergency and a formal report being issued. All clinicians have some training in interpreting chest X rays.” Source location Response from The Royal College of Paediatrics and Child Health
Open published response
6 Feb 2026 Mr Stephen Martin Rhodes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2
Failure to adequately scrutinise laboratory blood test results View source Failure to prominently flag abnormal laboratory results View source
Linked responses
NHS England Quarry Bank Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
NHS England
Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
View source
NHS England
Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
View source
Quarry Bank Medical Centre
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
View source
Quarry Bank Medical Centre
Implement the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
View source
Quarry Bank Medical Centre
Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
View source
Quarry Bank Medical Centre
Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
View source
Quarry Bank Medical Centre
Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
View source
Quarry Bank Medical Centre
Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
View source
Quarry Bank Medical Centre
Develop and operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
View source
Quarry Bank Medical Centre
Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
View source
NHS England
Promote wider standardisation of pathology result-flagging conventions.
View source See 8 more actions
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AI-generated summary
Mr Stephen Martin Rhodes · 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 Stephen Martin Rhodes, who had progressive shortness of breath, had a markedly raised NT-proBNP result that was filed in the mistaken belief that there was no abnormal finding. He collapsed and died after developing a cardiac arrest while working as a delivery driver on 11 March 2025. The principal concern was that the blood test result was not adequately scrutinised and the recommended specialist referral and echocardiography within two weeks did not occur; the inquest conclusion was narrative, with natural causes contributed to by neglect.
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 adequately scrutinise laboratory blood test results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP . The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red.
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Source location Mr Stephen Martin Rhodes · Prevention of Future Deaths report
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 prominently flag abnormal laboratory results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP. The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red .
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Source location Mr Stephen Martin Rhodes · Prevention of Future Deaths report
Open source report
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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 Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
Verbatim wording from the response “A pilot is underway to establish and prove how a DAPB4101 pathology report can be sent from labs and ingested by GP practices safely. This will involve working with the GP system supplier, and the three pathology middleware suppliers that enable national coverage for lab to GP reporting as well as with Berkshire & Surrey NHS Pathology Services. Once the pilot has completed, implementing DAPB4101 will then go onto NHS England's GP system suppliers’ managed roadmap of development work, leading to national roll-out.” Source location 2026-0083 - Response from NHS England
Open published response
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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 guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
Verbatim wording from the response “While operational arrangements are managed at individual practice level, NHS England has published several resources available to support safe systems of work, including:” Source location 2026-0083 - Response from NHS England
Open published response
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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 Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Verbatim wording from the response “1. Laboratory Reporting (actioned 14 March 2025): On 14 March 2025, the Practice wrote to Russells Hall Hospital laboratory to notify them that their reports were not including an alert on raised NT-proBNP results. The laboratory conducted a review and their reports now include an alert when NT-proBNP results are raised. As these results now carry a laboratory red flag indicator, they are correctly identified during the Practice’s manual filtering process and routed into the action-required category for clinical review. The laboratory has also updated its report format so that all abnormal results are flagged on the first page of each report. This change will benefit all practices receiving reports from this laboratory and materially reduces the risk of a similar event occurring across the wider system.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Implement the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
Verbatim wording from the response “2. MY Bot AI Triage System (implemented 18 February 2026): The Practice introduced the MY bot AI triage system on 18 February 2026 following a careful, phased assessment to ensure clinical accuracy and safety prior to full adoption. MY bot works by applying an intelligent filter to incoming blood test results, segregating them into two categories: results that require clinical action and results that do not require action. This enables each GP to focus their review directly on results requiring” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
Verbatim wording from the response “3. Revised Results Management SOP (18 February 2026): The Results Management Policy has been formally reviewed and reissued. The updated SOP explicitly mandates that the requesting clinician retains responsibility for the review, interpretation, actioning, and filing of all investigation results within 24 hours of availability. An automated alert is generated where results remain unfiled beyond this defined timeframe, with escalation to the clinical lead where defined backlog thresholds are exceeded.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
Verbatim wording from the response “4. Mandatory Same-Day Protocol for Raised NT-proBNP (18 February 2026): A mandatory same-day clinical review and documented action protocol has been introduced for all NT-proBNP values exceeding 400 – the threshold above which results are considered abnormal. The Practice has deliberately adopted this more conservative threshold rather than the NICE urgent referral threshold of >2000, to ensure that any raised NT-proBNP result, however early in its trajectory, receives prompt clinical attention on the day of receipt without exception.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
Verbatim wording from the response “5. High-Risk Biomarker Escalation Framework and Abnormal Alert System (18 February 2026): The “Abnormal Alert” system has been introduced within EMIS Web as an additional safety check. A defined list of critical biomarkers – including NT-proBNP, markedly abnormal potassium, CRP, and PSA – has been agreed, with results exceeding defined thresholds flagged for enhanced scrutiny. No result carrying a laboratory recommendation for onward referral may now be filed without documented clinician acknowledgment. Where a referral recommendation is not followed, a documented clinical reason must be recorded.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
Verbatim wording from the response “6. Cross-Filing Safeguard and Secondary Review (18 February 2026): Where results are reviewed and filed by a clinician other than the requesting GP, that clinician must send the requesting GP a task to review the results upon their return, ensuring a secondary review by the clinician with full knowledge of the clinical context. A secondary review safeguard has additionally been introduced for specified critical cardiac biomarkers to provide additional oversight where results exceed urgent referral criteria.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
Verbatim wording from the response “8. Clinical Audit Programme (18 February 2026): The Practice has developed a programme of practice-level clinical audits targeting results of high clinical significance, designed to provide ongoing assurance that abnormal results are identified, actioned, and that time-bound referral recommendations are completed within the specified timeframe. The audit programme includes NT-proBNP and BNP,” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
Verbatim wording from the response “PSA, and other clinically significant markers, to be expanded through ongoing clinical governance review. Audits are conducted on a fortnightly basis with outcomes reported to the monthly clinical governance meeting, at which results management is now a standing agenda item. A quarterly audit of NT-proBNP results and associated referral pathways will be conducted for a 12-month period to provide sustained assurance of compliance. The initial audit has confirmed that no other raised results have been missed.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
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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 Promote wider standardisation of pathology result-flagging conventions.
Verbatim wording from the response “The Pathology Transformation and Interoperability Programme in NHS England is currently undertaking the opportunity to promote:” Source location 2026-0083 - Response from NHS England
Open published response
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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 Individual GP practices manage operational arrangements for reviewing, assigning and acting on pathology results.
Verbatim wording from the response “NHS England recognises the need for robust result review processes are needed at pace in busy practices and the ability to correctly assign and act on results.” Source location 2026-0083 - Response from NHS England
Open published response
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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 Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Verbatim wording from the response “The responsibility for the formatting, structure and presentation of pathology results sits primarily with:” Source location 2026-0083 - Response from NHS England
Open published response
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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 England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
Verbatim wording from the response “The Practice notes that a copy of the Regulation 28 Report has been sent to NHS England and fully supports the Coroner’s suggestion that NHS England may wish to review national guidance for laboratories regarding the flagging of abnormal results. The Practice’s direct experience in this case demonstrates that a laboratory’s failure to flag an abnormal result at source can silently circumvent even well-designed electronic filtering systems at practice level. National standardisation of laboratory alert protocols would represent a meaningful and systemic patient safety improvement. The Practice would welcome any such guidance.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
26 Sep 2025 Honoria Culshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of sharing pacemaker wound test results with the surgical team View source
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AI-generated summary
Honoria Culshaw · 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
Honoria Culshaw developed an infected pacemaker site and later underwent surgery to extract the pacemaker. She subsequently developed fatal pneumonia and died on 25 October 2024. The principal concern was that information about a positive wound swab may not have been shared or properly considered, potentially delaying extraction of the pacemaker.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of sharing pacemaker wound test results with the surgical team
Wider context from the report “I heard evidence that on the 15th August 2024, a swab from the pacemaker wound tested positive for the Morganella Morganii bacteria, which was also found post-mortem. It is not clear from the evidence who on the surgical team was made aware of this result, and whether it was properly taken into consideration as part of the pre-operative risk assessment. Mrs. Culshaw had her pacemaker re-sited on the 20th August 2024.
I found that Mrs. Culshaw’s experience of persistent and prolonged infection depleted her physiological reserve and contributed to her succumbing to a fatal pneumonia on the 25th October 2024.
I am concerned that this lack of information sharing of test results , which in this case may have resulted in an extraction process not taking place at the earliest opportunity.
” Source location Honoria Culshaw · Prevention of Future Deaths report
Open source report
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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 Strengthen the wound-swab tracking and review documentation to record swab timing, result review, clinician notification and associated treatment.
Verbatim wording from the response “• A wound swab tracking document managed by the Cardiology Catheter Laboratory (CCL) team has been strengthened. This includes a daily check, details of results received, and which clinicians have been informed.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add wound-swab results to the WHO checklist, using an interim sticker until the revised form is approved, redesigned and printed.
Verbatim wording from the response “• “Wound swab check” has been added to the WHO checklist.¹ The WHO checklist is carried out immediately prior to the procedure with the participation of the full team undertaking the procedure.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Microbiology telephone notification was not required because the superficial wound swab result did not meet critical-result reporting criteria.
Verbatim wording from the response “Progress: Microbiology advise they will telephone through critical results about virulent organisms such as group A streptococcus, or if it is from a normally sterile site, or if the organism has resistant markers of national concern.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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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 Harris Flex cannot automatically alert clinicians to pathology results, limiting automated result notification while IT work continues.
Verbatim wording from the response “The electronic system in place at the Trust does not have a facility to automatically alert the clinician and therefore there is a risk on the risk register (Datix ID 2176) ‘Harris Flex currently does not follow, or support UK medical workflows leading to delay or missed review of Pathology results’.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
Open published response
7 May 2025 Sybil Morgan-Gray · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure of blood gas machines to clearly indicate unrecordably low blood glucose levels View source
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AI-generated summary
Sybil Morgan-Gray · 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
Sybil Morgan-Gray developed hypoglycaemia in hospital, which was not recognised for several hours and resulted in a consequential brain injury. She later died from an infection arising from earlier abdominal surgery; the principal concern was that blood gas analysers displayed unrecordably low glucose as “- - -”, which could be misinterpreted and delay clinical action.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of blood gas machines to clearly indicate unrecordably low blood glucose levels
Wider context from the report “1. A concern regarding the interpretation of blood gas machine readings. Specifically, when blood glucose levels are unrecordably low, the machines report this as ‘- - -’. This display can be misinterpreted as indicating the sample is unanalysable, rather than accurately reflecting an extremely low glucose level. This misinterpretation could lead to delayed or inappropriate clinical responses, potentially resulting in future deaths.
It was unclear why the results are not recorded as ‘Low’ or similar.
” Source location Sybil Morgan-Gray · Prevention of Future Deaths report
Open source report
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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 Investigate whether interpretation of glucose and other out-of-range point-of-care analyser results presents a wider safety issue.
Verbatim wording from the response “It is therefore important that device users are familiar with any warnings or symbols displayed on the device and the recommended course of action, particularly when results fall outside of the reporting range. We have investigated whether there is a wider issue across all point of care analysers and can confirm that we have not identified any further safety signals reported through our Yellow Card scheme associated with the interpretation of glucose results, or any other point of care results, outside the reporting range.” Source location Response from Medicines & Healthcare products Regulatory Agency
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share applicable report details with the manufacturer for review through its ongoing post-market surveillance.
Verbatim wording from the response “It is our intention to share applicable details of this report with the manufacturer so that they can review this case as part of their on-going post market surveillance activities, and to work with the trust to resolve any identified training issues that may have arisen. We will also engage with NHS England colleagues to determine if any additional similar cases have been reported to Learn from Patient Safety Events and if there are, will work with NHSE to ensure appropriate training is in place.” Source location Response from Medicines & Healthcare products Regulatory Agency
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the trust to resolve any identified training issues relating to interpretation of analyser results.
Verbatim wording from the response “It is our intention to share applicable details of this report with the manufacturer so that they can review this case as part of their on-going post market surveillance activities, and to work with the trust to resolve any identified training issues that may have arisen. We will also engage with NHS England colleagues to determine if any additional similar cases have been reported to Learn from Patient Safety Events and if there are, will work with NHSE to ensure appropriate training is in place.” Source location Response from Medicines & Healthcare products Regulatory Agency
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.