British Cardiovascular Society

Private and voluntary organisations · Health professional body

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First report 25 Sep 2013•Latest report 23 Oct 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from British Cardiovascular Society linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Hireiti Kufletsion · 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

    Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis 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. The report was sent to British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves

    Wider context from the report

    “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa. ”
    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 British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications

    Wider context from the report

    “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients. ”
    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 British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient clexane dosing for pregnant women with mechanical valves

    Wider context from the report

    “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa. ”
    Open source report

  2. Inner South London

    AI-generated summary

    Anna Ulmer Ahmed · 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

    Anna Ulmer Ahmed, aged 30, was assessed by ambulance staff and later by her GP after experiencing chest pain; she died at home a few hours later from sudden adult cardiac death syndrome. The report raised concerns about low awareness of the condition in general practice and a lack of, or limited awareness of, guidelines for urgent referral of patients vulnerable to it.

    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 British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness of urgent-referral guidelines for patients vulnerable to SAD

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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 British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Generally low awareness of SAD in general practice

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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 British Cardiovascular Society; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidelines for urgent referral of patients vulnerable to SAD

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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

Data last updated 7 September 2026