Recurring concern

Failure to provide timely clinically required blood tests

First to latest report 25 Jul 2014 — 7 Feb 2026

Reports that mention this concern
22
Times this concern has been raised
23
Stated actions linked to this concern
16

What this concern includes

Includes failures to arrange, collect, process or complete clinically required blood tests promptly, including delays occurring overnight, in emergency care or in prison healthcare, where the blood-testing delay can impair diagnosis, monitoring or treatment.

What is not included
  • Excludes non-blood diagnostic investigations, such as ECGs, imaging or urine tests, unless the assertion also specifically identifies a deficient blood-testing control.
  • Excludes failures to communicate or act on blood-test results when the blood test itself was completed and made available on time.
  • Excludes generic laboratory, staffing or communication deficiencies unless they directly cause delayed, omitted or unavailable clinically required blood tests.
  • Excludes routine blood tests where no clinically required timeframe or safety consequence is identified.

Reports and published responses 22 reports

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

  1. Blackpool and the Fylde

    AI-generated summary

    Janet Springall · 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

    Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased risk.

    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 provide timely blood testing for suspected infection in ambulance-held patients

    Wider context from the report

    “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department. When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department. Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital. Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment. I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done. ”

    Source location

    Janet Springall · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Care Quality Commission will provide a separate response to the concerns.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 12 February 2026

    Open published response

  2. Devon, Plymouth and Torbay

    AI-generated summary

    Pamela George · 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

    Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.

    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 carry out regular blood tests

    Wider context from the report

    “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed. ”

    Source location

    Pamela George · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.

    Verbatim wording from the response

    “• The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes:”

    Source location

    Response from Cann House
    Page 1 · response
    Published 3 February 2026

    Open published response

  3. Hampshire, Portsmouth Southampton

    AI-generated summary

    Shre Kumar CHATTERJEE · 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

    Shre Chatterjee developed a sudden severe headache in August 2023 and died at University Hospital Southampton on 12 October 2023 from an acute on chronic subdural haematoma. The report identifies repeated unsuccessful attempts to obtain timely face-to-face medical assessment, including missed opportunities to refer him for hospital assessment and a CT scan. It also raises concern that out-of-hours and 111 doctors could not directly book urgent appointments with some GP surgeries.

    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

    Unavailability of blood tests and imaging in Urgent Care Centres

    Wider context from the report

    “During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”

    Source location

    Shre Kumar CHATTERJEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Milton Keynes

    AI-generated summary

    Karl Fraser DUNSTAN · 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

    Karl Dunstan died at Milton Keynes University Hospital on 14 January 2025 from a pulmonary embolism arising from a deep vein thrombosis. The investigation identified missed opportunities to investigate and treat the pulmonary embolism, including the declined CT pulmonary angiogram request, failure to complete D-dimer testing, and lack of emergency treatment when his condition deteriorated.

    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 complete D-dimer testing during pulmonary embolism investigation

    Wider context from the report

    “That the investigation of a pulmonary embolism was not carried out in accordance with NICE guidance, and a request for a CT pulmonary angiogram by the consultant was rejected by the radiology department because it did not meet the threshold of the Wells score used by the Hospital and yet a D-dimer test was not completed, that if positive, would have resulted in a CTPA. The policy and procedure is in need of an urgent review. ”

    Source location

    Karl Fraser DUNSTAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Held cross-departmental discussions to review and optimise pulmonary embolism screening and triage systems across patient groups.

    Verbatim wording from the response

    “In light of this case, we have:”

    Source location

    Response from Milton Keynes University Hospital
    Page 4 · response
    Published 14 July 2025

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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

    Undertake an audit of pulmonary embolism pick-up rates against recorded Wells scores and D-dimer use, including appropriateness of scoring-system application.

    Verbatim wording from the response

    “We do plan to undertake an audit to look at pick up rates (of pulmonary embolus) versus the Wells score and D-dimer. Clearly it is important to understand whether the request and scoring systems are being used appropriately. Specifically:”

    Source location

    Response from Milton Keynes University Hospital
    Page 4 · response
    Published 14 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trial and evaluate for six months a process escalating unapproved CTPA requests to the duty radiologist, with requester contact when further information or investigation is needed.

    Verbatim wording from the response

    “We plan to trial a system for six months (and evaluate) whereby if a CTPA cannot be approved by the radiographer, it will be brought to the attention of the duty radiologist. If the radiologist is satisfied (from the request narrative) that a D-dimer is not required, he/she may authorise the study. If the radiologist is not satisfied, efforts will be made by the radiographer to contact the requester by bleep / telephone to inform them of this and to invite them to undertake a D-dimer or to discuss further investigation with the duty radiologist as appropriate (in addition to the current system of the primary communication being electronic).”

    Source location

    Response from Milton Keynes University Hospital
    Page 5 · response
    Published 14 July 2025

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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

    The Trust considers management reasonable and says earlier D-dimer or CTPA would not probably have changed the outcome.

    Verbatim wording from the response

    “I shall come on to address the substantive content of the regulation 28 report, but I do find it necessary to comment on the text of your narrative conclusion before doing so. Specifically, you assert that a failure to undertake a D-dimer test and therefore to obtain an urgent CT pulmonary angiogram (to make a definitive diagnosis of a pulmonary embolus) meant that thrombolysis was not started when he later collapsed (in cardiorespiratory arrest). You imply that thrombolysis would perhaps have altered the sad outcome in describing ‘missed opportunities [which] more than minimally contributed to his death’. For avoidance of doubt, we consider that whilst a different course of events and actions might potentially have influenced the ultimate outcome, it would not – on the balance of probabilities – have done so.”

    Source location

    Response from Milton Keynes University Hospital
    Page 1 · response
    Published 14 July 2025

    Open published response

  5. Cambridgeshire and Peterborough

    AI-generated summary

    Christian James Gabriel Hobbs · 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

    Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

    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

    Delays in obtaining the first blood gas

    Wider context from the report

    “POINT G – BLOOD GASES/ ELEVATED LACTATE There was a delay in getting the first blood gas. A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this. ”

    Source location

    Christian James Gabriel Hobbs · Prevention of Future Deaths report
    Page 17 · 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

    Expand sepsis education and training through dedicated sepsis nurses, protocol-adherence monitoring and bi-monthly sepsis meetings.

    Verbatim wording from the response

    “G. Blood Gases/Elevated Lactate The sepsis guidelines are clear and once sepsis is suspected a venous blood gas should have been obtained when the initial blood samples were obtained at 19:00h. The Trust has since expanded its sepsis education and training, employing dedicated sepsis nurses who deliver the education and training, and monitor adherence to protocols and hold bi-monthly sepsis meetings.”

    Source location

    Response from North West Anglia NHS Foundation Trust
    Page 3 · response
    Published 15 April 2025

    Open published response

  6. Essex

    AI-generated summary

    LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

    Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and 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 obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients

    Wider context from the report

    “(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

    Source location

    LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.

    Verbatim wording from the response

    “Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 4 · response
    Published 18 December 2024

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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

    Audit obstetric bleeding-strategy compliance and review postpartum-haemorrhage cases to feed learning to governance and national study teams.

    Verbatim wording from the response

    “To date, we have 91% training compliance of our target group of clinicians which is being reassessed after a new rotation of staff to ensure we remain above 90%. To assess our compliance of the strategy audits (first 30 consecutive births) and case note reviews (first ten consecutive births with 1 litre loss or more) are undertaken at month one, four, seven and ten after the start of the study. Due to training of staff and development of a standard operating procedure (attached) taking a number of months the strategy did not commence till 21st November 2024 with the last few months taken to drive the uptake of the bundle. To reflect this, the service undertook an additional audit in January which showed a 75% compliance across the board for risk assessments, measured blood loss and appropriate TEG testing.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 5 · response
    Published 18 December 2024

    Open published response

  7. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Sebastian Harry DANIELS · 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

    Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.

    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 clozapine services to provide annual physical-health blood testing

    Wider context from the report

    “3. In relation to the blood tests required under the clozapine guidelines I was informed that Southern Health take the monthly blood tests and run these in the clozapine clinic. However the blood tests required of the annual physical health checks are not taken by the Southern Health staff but rather patients are required to attend phlebotomy services elsewhere for the blood to be taken. I heard evidence during the inquest that Mr Daniels had missed some of these blood test appointments which meant his full tests were not carried out when expected. Clozapine is prescribed only to patients suffering from an enduring mental health condition for whom other medication has not been effective which indicates that they may be at risk of having difficulty managing appointments. I heard evidence from the consultant psychiatrist responsible for Mr Daniel’s treatment that they were not permitted to take the blood samples and submit them to the local laboratory for testing. I was informed that the Southern Health staff had requested to be able to do this to avoid the patient having to attend another appointment. I have reviewed further information provided after the inquest by the Clinical Director of Southern Health. She has explained that they lack the facilities to complete the full blood tests and the lack the resources to take and deliver samples to the laboratories; noting that no community mental health teams in their trust routinely provide phlebotomy services. She has advised that they are focussed on better communication with primary care and assertive outreach where necessary. I remain concerned that patients on high risk medication, who by the nature of their mental health condition may struggle to attend appointments, are required to arrange or attend separate blood tests. I note that clozapine clinic staff also blood monthly and that the physical health reviews are carried out by doctors all of whom should be capable of taking a blood sample for submission to a laboratory. ”

    Source location

    Sebastian Harry DANIELS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operationalise blood sampling in Mid and North Hampshire Clozapine clinics using equipment, blood transport arrangements and a staff rota.

    Verbatim wording from the response

    “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.”

    Source location

    Response from Southern Health NHS Foundation Trust
    Page 1 · response
    Published 26 September 2023

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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 systems to identify required blood tests, record completed samples, optimise patient records and track results for Mid and North Hampshire Clozapine clinics.

    Verbatim wording from the response

    “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.”

    Source location

    Response from Southern Health NHS Foundation Trust
    Page 1 · response
    Published 26 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review variation in service provision across Clozapine clinics and use the findings to inform improvement.

    Verbatim wording from the response

    “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.”

    Source location

    Response from Southern Health NHS Foundation Trust
    Page 1 · response
    Published 26 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish consistent principles across Clozapine clinics for annual health-check capacity, preferred onsite blood sampling and robust results-review systems.

    Verbatim wording from the response

    “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.”

    Source location

    Response from Southern Health NHS Foundation Trust
    Page 1 · response
    Published 26 September 2023

    Open published response

  8. West Yorkshire Eastern

    AI-generated summary

    Carol Ann Hatch · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her death.

    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

    Delays in urgent blood sample delivery and reporting

    Wider context from the report

    “10. Blood samples taken at 8.02 am were not delivered to the laboratory until 9.06 am and then not reported on until 10.21 am as they had not been marked as ‘urgent’. This also reflects a failure to appreciate the gravity of the situation. ”

    Source location

    Carol Ann Hatch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of urgent sickle cell trait testing for previously processed non-UK selection candidates

    Wider context from the report

    “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait. If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester City

    AI-generated summary

    Margaret Bernadette WILSON · 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

    Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.

    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 perform a guideline-compliant blood test for Endocarditis

    Wider context from the report

    “1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease. 2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome. In addition it was later recognised that the finger symptoms were most likely due to Endocarditis. ”

    Source location

    Margaret Bernadette WILSON · 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