Recipient

Lathom Road Medical Centre

First report 4 May 2022•Latest report 4 May 2022

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 5

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.

100%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

4 May2022
Inner North London
Concerns raised4
1. Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill
2. Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill
3. Failure to record significantly elevated blood pressure readings in the medical record
1. Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Maintain staff vigilance to ensure patients using the machine submit their readings before leaving.
  Stated in progress
2. Action
  Relocate the blood-pressure machine to the opposite reception-area wall to improve staff oversight while preserving confidentiality.
  Stated planned
3. Action
  Place a sign above the blood-pressure machine directing patients to give their readings to reception.
  Stated completed
Respondent positions 1
1. Position
  Continuous staff supervision of every patient using the blood pressure machine is not always possible because reception staff are already occupied with front-desk duties.
  Unable to act
AI-generated summary

Lauren Louise MURDOCK · 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

Lauren Murdock died from a myocardial infarction at age 27. Concerns included a significantly elevated blood pressure reading that was not recorded in her medical record or brought to the GP’s attention, and errors in assessing clot and cardiovascular risks when prescribing the combined contraceptive pill. She died ten days after the elevated blood pressure reading was taken.

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 Lathom Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill
Wider context from the report
“The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so. However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk. She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years. If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action. She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary. If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all. ”
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 Lathom Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill
Wider context from the report
“The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so. However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk. She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years. If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action. She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary. If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all. ”
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 Lathom Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to record significantly elevated blood pressure readings in the medical record
Wider context from the report
“At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98. That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record, and it was certainly not brought to Dr ████████ attention. ”
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 Lathom Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention
Wider context from the report
“At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98. That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record, and it was certainly not brought to Dr ████████ attention. ”
Open source report
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
Maintain staff vigilance to ensure patients using the machine submit their readings before leaving.

Verbatim wording from the response
“Staff to remain vigilant of any patients using the machine to ensure patients do not leave without submitting a reading.”

Source location
Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022
Open published response
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
Relocate the blood-pressure machine to the opposite reception-area wall to improve staff oversight while preserving confidentiality.

Verbatim wording from the response
“1. Re-site the machine closer to the reception desk so staff can keep a closer eye on the patients using the machine, the only problem with this is that it can’t be placed right next to the reception desk as it would raise confidentiality issues with the patients already queuing at the front desk. Reception staff suggested to place the machine on the opposite wall of the reception area where they would have better oversight of the patient – we shall try this.”

Source location
Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022
Open published response
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
Place a sign above the blood-pressure machine directing patients to give their readings to reception.

Verbatim wording from the response
“A sign has been placed above the blood pressure machine guiding patients to hand the reading to the receptionist once checked.”

Source location
Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022
Open published response
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
Continuous staff supervision of every patient using the blood pressure machine is not always possible because reception staff are already occupied with front-desk duties.

Verbatim wording from the response
“5. Dr ████████ suggested having a dedicated member of staff to supervise each patient checking their blood pressure throughout the process. ████████ mentioned that this is not always going to be possible as staff are already busy at the front desk and wouldn’t always have time to supervise every patient. We agreed that if staff members are free then they should try to stay with the patient though the monitoring process, failing that they should give the patient clear instructions to submit their readings to the front desk.”

Source location
Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill

Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill

Failure to record significantly elevated blood pressure readings in the medical record

Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 3

Respondent positions 1