30 Oct 2015 Mary Catherine Bloom · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to consult a haematologist before heparin infusion for very low-weight patients View source Failure to weigh patients before commencing heparin infusion View source Failure to obtain baseline bloods and subsequent APTT monitoring for heparin administration View source Insufficient visibility of the heparin administration poster’s direction to seek haematology advice for underweight patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Catherine Bloom · 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
Mary Catherine Bloom, who had dementia and reduced oral intake, was admitted with probable left-leg ischaemia and died in hospital on 4 February 2014. Concerns included failures to record her weight, consult haematology, obtain baseline and follow-up blood tests, and make the heparin administration guidance sufficiently visible. There was also no discussion with her next of kin before a DNAR order was placed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult a haematologist before heparin infusion for very low-weight patients
Wider context from the report “1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin.
2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy.
3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to weigh patients before commencing heparin infusion
Wider context from the report “1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin.
2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy.
3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain baseline bloods and subsequent APTT monitoring for heparin administration
Wider context from the report “1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin.
2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy.
3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient visibility of the heparin administration poster’s direction to seek haematology advice for underweight patients
Wider context from the report “The poster for the administration of heparin include a direction that:
An obese/underweight patient who weigh over 131 kilograms and under 40 kilograms should be treated on an individual basis. Please seek haematology advice.
This direction is written in very small writing at the bottom of the heparin administration poster. It appears to have been missed by 2 doctors involved in the prescribing of heparin to Mrs Bloom. There is concern that this may have been missed as it was not sufficiently visible on the poster.
” 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 Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.
Verbatim wording from the response “In your letter you acknowledge receipt of three new policies that have been put in place by the Trust following the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the requirement for a haematologist to be consulted where a patient is at the extremes of weight. The reasoning for this decision is as follows.” Source location 2015-0417-Response
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 Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.
Verbatim wording from the response “The Trust’s new policy is for a weight based bolus and then a weight based infusion the latter within weight ranges. Even with a patient of 25kg the infusion would be at 20iu/kg/hr which is a very reasonable infusion rate and in line with recognised dosage rates even at this weight. The APPTT must be checked at 6 hours and this allows the dose to be adjusted within recognised time intervals. We therefore feel that the safeguards are in place as we have moved to an entirely weight based formulation. As an extra safeguard the guideline, following the concerns you raised, now also states that if the APPTT at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.” Source location 2015-0417-Response
Open published response
1 Jun 2015 Ronald Alfred Smith · Prevention of Future Deaths report London (East)
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Concerns raised 2 Failure to make flexible sigmoidoscopy equipment available out of hours View source Lack of a clearly communicated and accessible protocol for out-of-hours access to flexible sigmoidoscopy equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ronald Alfred Smith · 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
Ronald Alfred Smith was admitted to Queen’s Hospital with a sigmoid volvulus causing bowel obstruction and bowel ischaemia, and died on 2 February 2014 before a flexible sigmoidoscopy could be performed. The principal concern was that staff could not access the equipment out of hours, and that no clear protocol for doing so had been established despite the identified need.
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. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make flexible sigmoidoscopy equipment available out of hours
Wider context from the report “there was a failure in this case to access a flexible sigmoidoscope out of hours . This item of surgical equipment was not available to the surgical registrar who considered that this was the only intervention that may have benefitted the patient.
Mr Smith’s death occurred in February 2014. The Trust’s root cause analysis report identified the need for a clearly communicated and accessible protocol for access to flexible sigmoidoscopies out of hours. Notwithstanding the period of 16 months which has elapsed since Mr Smith’s death there is still no protocol in place at the Trust. I consider that action should be taken to expedite a clear procedure for such equipment to be available to staff out of hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clearly communicated and accessible protocol for out-of-hours access to flexible sigmoidoscopy equipment
Wider context from the report “there was a failure in this case to access a flexible sigmoidoscope out of hours. This item of surgical equipment was not available to the surgical registrar who considered that this was the only intervention that may have benefitted the patient.
Mr Smith’s death occurred in February 2014. The Trust’s root cause analysis report identified the need for a clearly communicated and accessible protocol for access to flexible sigmoidoscopies out of hours . Notwithstanding the period of 16 months which has elapsed since Mr Smith’s death there is still no protocol in place at the Trust . I consider that action should be taken to expedite a clear procedure for such equipment to be available to staff out of hours.
” Open source report
2 Oct 2014 Mr Pether · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 4 Failure to reassess treatment options in response to significant treatment delays View source Failure to identify the source of infection during clinical deterioration View source Failure to conduct detailed assessment and re-consult treatment options during clinical deterioration View source Failure to conduct focused checks of limb viability View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Pether · 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 Pether was admitted after a fall that caused a right femur peri-prosthetic fracture, with a pre-existing infection and an open fracture increasing the risk of infection. Transfer for complex surgery was delayed, and records identified no focused medical or nursing checks of limb viability between 11 and 20 December 2012. The wound was found to be infected and necrotic on 20 December; despite surgery, amputation and intensive care, Mr Pether deteriorated and died from left ventricular failure after developing multi-organ failure.
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. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess treatment options in response to significant treatment delays
Wider context from the report “2. Between the 11 December and the 20 December 2012 the only medical entries for plan of care related to the fact that Mr Pether was “awaiting Stanmore”. There is no evidence of any discussion as to the effect of this significant delay in the provision of treatment and whether the options for his treatment should have been re-considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the source of infection during clinical deterioration
Wider context from the report “4. Even on the 20 December 2012 when Mr Pether’s clinical condition significantly deteriorated (acute kidney injury and chest infection now clearly manifesting), the orthopaedic team failed to identify the source of the infection . It would appear that it was the family that raised concerns about Mr Pether’s breathlessness which led to a review by the Medical Registrar. The Medical Registrar carried out a very full assessment and identified the likely source of sepsis in the right leg. She involved the microbiology team and requested a review by ITU and the orthopaedic registrar. After this time, Mr Pether received a good standard of care, but at this stage, his prognosis was very poor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct detailed assessment and re-consult treatment options during clinical deterioration
Wider context from the report “3. By the 19 December 2012, there was a raised CRP and evidence of an acute kidney injury . It is certainly arguable that a more detailed assessment of the patient at that time and a re-consultation of options by the orthopaedic team should have taken place at that time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct focused checks of limb viability
Wider context from the report “1. Despite the clear risk of infection in Mr Pether’s wound there were no medical record entries by the orthopaedic medical team or nursing team on Amber ward, of any focussed checks upon the viability of Mr Pether’s limb between the 11 December and the 20 December 2012 . This would appear to be a very basic standard of care required on an orthopaedic ward.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations