Recipient

Head of Clinical Quality

Pin Request correction

First report 15 May 2024•Latest report 15 May 2024

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 Head of Clinical Quality linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Gary David Ash · 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

    Gary David Ash died at Queen's Hospital on 25 June 2019 after developing serotonin syndrome shortly after receiving a general anaesthetic without valid consent. He subsequently received large amounts of intravenous fluid, developed fluid overload and pulmonary oedema, and suffered a cardiac arrest. The principal concerns included knowledge and management of neuroleptic malignant syndrome and serotonin syndrome, use of Dantrolene, fluid monitoring, and potential drug interactions affecting cardiac contractility.

    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 Head of Clinical Quality; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of neuroleptic malignant syndrome management and appropriate Dantrolene use

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Head of Clinical Quality; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of the Dantrolene–Labetalol interaction reducing cardiac contractility

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Head of Clinical Quality; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of serotonin syndrome diagnosis and risk following combined Fentanyl and Ondansetron use

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Head of Clinical Quality; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of Dantrolene-associated pulmonary oedema risk during intravenous fluid overload

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    Open source report
Back to top

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