Recurring concern

Unreliable recognition and assessment of anaemia

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First reported 5 Nov 2019•Latest report 16 Sep 2021

Definition

What this concern includes

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

Not included

Excludes generic shortages, reduced access or consultation-capacity concerns unless they directly impair recognition or assessment of anaemia.
Excludes nutritional, socioeconomic or pandemic-related causes of anaemia unless the report identifies a deficient anaemia-recognition or assessment control.
Excludes treatment, prescribing or follow-up failures occurring after anaemia has been adequately recognised and assessed.
Excludes failures concerning unrelated conditions or diagnostic processes without a specific anaemia connection.

Reports: 3
Individual concerns: 3
Date range: 2019–2021
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Covid-19 Pandemic Response Service1

Department of Health and Social Care1

NHS England1

NHS Greater Manchester Integrated Care Board1

NHS Pathways1

Northern Care Alliance NHS Foundation Trust1

Royal College of Nursing1

Royal College of Pathologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

16 Sep2021
West Yorkshire (Western)
Concerns raised1
1. Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Restore NHS services following pandemic disruption.
  Stated by NHS EnglandStated in progress
2. Action
  Repatriate redeployed public health nurses to health visiting services.
  Stated by NHS EnglandStated completed
3. Action
  Advise services not to redeploy professionals supporting children and families, and support provision to vulnerable families.
  Stated by NHS EnglandStated completed
1. Action
  Publish an updated health visiting and school nursing delivery model with commissioning guidance.
  Stated by NHS EnglandStated completed
AI-generated summary

Maya ZAB · Prevention of Future Deaths report

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

Report summary

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

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Restore NHS services following pandemic disruption.

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

Source location
2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Repatriate redeployed public health nurses to health visiting services.

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

Source location
2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021
Open published response
16 Dec2020
Cumbria
Concerns raised1
1. Failure of initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Using either COVID-19 or the pre-pandemic breathlessness pathway would have produced the same outcome: clinical assessment within one hour.
  Stated by NHS EnglandDisputes the concern
1. Position
  Non-clinical health advisors should not exercise clinical discretion; recorded medical history is shared with clinicians for subsequent assessment and decision-making.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Patricia Ann Douglas · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history
Wider context from the report
“(1) The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to the Covid service and does not seem to have given weight to the history of anaemia and transfusion. Could the pathway be improved to give better guidance to call handlers? ”
Source location
Patricia Ann Douglas · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

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

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

Source location
2020-0286-Response-from-NHS-Digital-Redacted
Page 2 · response
Published 7 January 2021
Open published response
Source evidence

How this respondent position was interpreted

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

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

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

Source location
2020-0286-Response-from-NHS-Digital-Redacted
Page 2 · response
Published 7 January 2021
Open published response
5 Nov2019
Manchester North
Concerns raised1
1. Failure to obtain ferritin levels for anaemia management
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Christopher Byron · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain ferritin levels for anaemia management
Wider context from the report
“1. In this case the Trust Guideline ‘Patient Blood Management of Medical Patients’ sets out the Pathway for the Management of Anaemia. In addition to this Trust documents there is NICE guidance for Anaemia – iron deficiency (revised 2018). Both of these documents include as a key factor the obtaining of ferritin levels, albeit the question as to the interpretation of such results will be dependant on the patients presenting condition. On the 30th December 2016 no sample was taken to check the ferritin levels. ”
Source location
Christopher Byron · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to obtain ferritin levels for anaemia management

Actions described in response 4

Respondent positions 2