20 Aug 2024 Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report East London
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Concerns raised 5 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom View source Insufficient education of parents and patients on safe AAI use when in doubt View source Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings View source Lack of sufficiently clear distinction between anaphylactic and mild reactions View source Unavailability of AAI stock in chemists for emergencies View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Review CPD requirements and consider proposing changes to medical-emergency recommendations.
View source
Action
Write to NICE requesting review of anaphylaxis symptoms and related guidance for dental professionals.
View source
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AI-generated summary
Hannah Enola Ayamo Jacobs · 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
Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.
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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Wider context from the report “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of parents and patients on safe AAI use when in doubt
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT .
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Wider context from the report “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear distinction between anaphylactic and mild reactions
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction , and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AAI stock in chemists for emergencies
Wider context from the report “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies .
” 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 Review CPD requirements and consider proposing changes to medical-emergency recommendations.
Verbatim wording from the response “We are currently in the process of reviewing our CPD requirements, and we will consider whether we should propose changes to the recommendations regarding medical emergencies as part of the review. The review is expected to conclude in 2025, but some potential changes would require legislative changes, the timing of which is not under our control.” Source location Response from General Dental Council
Open published response
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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 Write to NICE requesting review of anaphylaxis symptoms and related guidance for dental professionals.
Verbatim wording from the response “Whilst I note your concern that dental professionals did not recognise the early symptoms of anaphylaxis, I also note that the symptom of excessive salivation is not listed as a potential symptom in the NICE guidance. We will write to NICE to highlight this, and to ask them to consider reviewing the listed symptoms of anaphylaxis and their guidance to dental professionals more broadly.” Source location Response from General Dental Council
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 Potential CPD changes requiring legislation may be delayed because the timing of legislative changes is outside the respondent’s control.
Verbatim wording from the response “We are currently in the process of reviewing our CPD requirements, and we will consider whether we should propose changes to the recommendations regarding medical emergencies as part of the review. The review is expected to conclude in 2025, but some potential changes would require legislative changes, the timing of which is not under our control.” Source location Response from General Dental Council
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 The current standards and guidance provide clear obligations, so additional or different standards are not currently considered necessary.
Verbatim wording from the response “The current framework of standards and guidance sets out clear obligations for dental professionals to have appropriate training and keep medication on their premises to use in the event of a medical emergency. I think that it is appropriate to continue to require adherence to the RCG as set out at Standard 1.5 and other appropriate guidance, including the NICE guidance as set out in Standard 7.1.” Source location Response from General Dental Council
Open published response
Concerns raised 1 Failure to limit publication of detailed undetermined allegations during interim proceedings View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Review the policy governing publication of Interim Order outcomes to balance open justice with registrants’ interests.
View source
Action
Review guidance and arrangements governing whether Interim Order hearings are held in public or private.
View source
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AI-generated summary
Barry Anthony LALL · 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
Barry Anthony LALL was a dentist whose fitness to practise was being investigated by the General Dental Council after concerns about his dental work. He was dismissed from his employment and later reported anxiety, depression and fleeting suicidal thoughts. The principal concern was the level of detail about undetermined allegations published on the GDC website during interim proceedings, and the potential detrimental effect on the mental health of those undergoing similar processes.
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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Failure to limit publication of detailed undetermined allegations during interim proceedings
Wider context from the report “Whilst it is accepted that the public should have knowledge of concerns raised with regards to a registered dental practitioner, my concern is regarding the level of detail placed on the GDC website in respect of those concerns, particularly when a case is at a stage where the proceedings have not been concluded and the issues not yet determined one way or another . In this case the report ran to 7 pages and set out in detail the allegations made under the 'background section' and then further detail of the allegations by way of documenting the submissions made by the Counsel acting on behalf of the GDC.
Whilst I accept that the report states in its preamble that "It is not the role of the IOC to make findings of fact in relation to any charge" the report detailed significant allegations, (which Mr Lall contested) which were undetermined by the GDC at that time. The report was then made available to the public via the GDC website .
Given that this was an interim order only, my concern is whether the level of detail provided to the public at that stage of proceedings, was necessary or required . The family gave evidence at the inquest of Mr Lall that he was "an extremely private individual so the impact this had on his mental health was tremendous." By putting detailed allegations into the public domain via the GDC website, at a stage before any final determination has taken place , I am concerned that others going through a similar process may also suffer a detrimental effect to their mental health. Consequently, in my view, there exists a risk that future deaths will occur.
” 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 Review the policy governing publication of Interim Order outcomes to balance open justice with registrants’ interests.
Verbatim wording from the response “in relation to our legal framework under review. Work to review the Guidance and the Policy and reviewing our position in relation to holding hearings in public had already been started by our Policy Team prior to receiving your report. Following the sad news of Mr Lall’s death and your Report, this work has been prioritised.” Source location Response from General Dental Council
Open published response
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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 Review guidance and arrangements governing whether Interim Order hearings are held in public or private.
Verbatim wording from the response “in relation to our legal framework under review. Work to review the Guidance and the Policy and reviewing our position in relation to holding hearings in public had already been started by our Policy Team prior to receiving your report. Following the sad news of Mr Lall’s death and your Report, this work has been prioritised.” Source location Response from General Dental Council
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 Open-justice requirements, published interim-order reasons and discretion to hold hearings privately currently address transparency and registrant-protection concerns.
Verbatim wording from the response “In pursuit of the overarching objective of public protection and of maintaining confidence in the professions it is important that the public can see where the GDC takes substantive action including, in the most serious cases, erasure and suspension. It is also important, particularly given the time it takes to get to a substantive hearing, that the public can see that immediate risks are addressed. The latter being undertaken through the IO process.” Source location Response from General Dental Council
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 Changes to the statutory Rules cannot be implemented solely by the regulator and may take longer because approval is outside its full control.
Verbatim wording from the response “This work is reviewing the policy in relation to the publication of outcomes of IOs and, due to the overlapping nature of the issues involved, the position set out in the Rules in relation to holding IO hearings and the guidance provided to the panel in relation to holding hearings in public or private is also being reviewed. The aim of the review is to ensure that we are correctly balancing the public interest in open justice against the interests of the registrant, particularly when considering as yet untested allegations. The timeframe for completion of this work depends on the outcome of the review. In some circumstances public consultation to any changes that we may wish to make is required, which will inevitably mean a longer timeframe.” Source location Response from General Dental Council
Open published response
Concerns raised 3 Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR View source Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals View source Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction View source
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
Patricia Margaret Thomas · 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 Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.
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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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 General Dental Council; that does not assign responsibility.
PFD Monitor interpretation Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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