Recipient

Barts Heart CentreIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 7 Mar 2019•Latest report 7 Mar 2019

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Barts Heart Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Director, Barts Heart Centre, St Bartholomew's Hospital.

    City of London

    AI-generated summary

    CHAND ALI · 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

    Chand Ali, a 78-year-old man with severe end-stage heart failure and diabetes, was admitted to hospital with fluid overload and decompensated heart failure and died later that day. Cyclizine was administered intravenously despite cautions concerning its use in severe heart failure. Concerns included its routine use without individual risk-benefit assessment, the lack of monitoring of deaths following recent cyclizine use, and the absence of a comprehensive review of alternative antiemetics.

    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 Barts Heart Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to require individualized risk-benefit justification for cyclizine prescribing in severe heart failure

    Wider context from the report

    “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously. The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription. Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture. It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use. ”
    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 Barts Heart Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of monitoring and analysis of deaths following recent cyclizine use

    Wider context from the report

    “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously. The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription. Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture. It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use. ”
    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 Barts Heart Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of comprehensive review of available alternative antiemetics

    Wider context from the report

    “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously. The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription. Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture. It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026