8 Apr 2022 Manhareen Kaur · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Lack of enhanced monitoring for babies at increased risk of early neonatal collapse after discharge to the postnatal ward View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Manhareen Kaur · 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
Manhareen Kaur, a baby born after a kiwi-assisted delivery, was found collapsed on the postnatal ward and died two days later after resuscitation and transfer to a neonatal unit. The principal concern was that babies at increased risk of early neonatal collapse were not provided enhanced monitoring of breathing, heart rate or oxygen saturations on the postnatal ward, leaving no intermediate monitoring option to support earlier detection and resuscitation.
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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of enhanced monitoring for babies at increased risk of early neonatal collapse after discharge to the postnatal ward
Wider context from the report “That babies at relative increased risk of early neonatal collapse due to deliveries complicated by factors such as assisted delivery, meconium staining, or early resuscitation assistance, are discharged back to the postnatal ward with no enhanced monitoring of their breathing, heart rate or oxygen saturations , unless they require admission to PICU or neonatal wards . In short that there is no “middle ground” which may allow early detection of collapse and thus increased chance of successful resuscitation should collapse occur.
” Open source report
10 May 2019 Karanbir Singh CHEEMA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to transmit allergy action plans to schools View source Lack of standardisation of allergy action plans across hospitals and schools View source Omission of second adrenaline auto-injector guidance from the emergency call algorithm View source Failure to ensure that school medication is in date View source Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement View source Delays in time-critical asthma and allergy review appointments View source Lack of school pupil understanding of allergies and the consequences of allergen exposure View source Failure to check or audit school allergy care plans and medication boxes View source Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure View source Insufficient availability of two adrenaline auto-injectors at all times View source Failure to communicate emergency adrenaline instructions effectively in school staff training View source Absence of emergency adrenaline instructions on EpiPen packaging View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karanbir Singh CHEEMA · 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
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit allergy action plans to schools
Wider context from the report “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school . There is no standardised approach to this , for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardisation of allergy action plans across hospitals and schools
Wider context from the report “4. Allergy action plans are not standardised across hospitals and schools , so messages are not as clearly delivered as they could be . This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of second adrenaline auto-injector guidance from the emergency call algorithm
Wider context from the report “11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given , because this is not contained within the algorithm . That could be remedied internationally.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that school medication is in date
Wider context from the report “3. Karanbir’s EpiPen was out of date . There must be systems in place to ensure that medication in schools is in date .
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement .
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in time-critical asthma and allergy review appointments
Wider context from the report “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital . By the time of his death four months later he had still not been seen again . There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of school pupil understanding of allergies and the consequences of allergen exposure
Wider context from the report “1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens . Targeted education about this would improve safety.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check or audit school allergy care plans and medication boxes
Wider context from the report “2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately , before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of two adrenaline auto-injectors at all times
Wider context from the report “7. Karanbir had one EpiPen at home, one at school and one at his father’s home . There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times .
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate emergency adrenaline instructions effectively in school staff training
Wider context from the report “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training .
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency adrenaline instructions on EpiPen packaging
Wider context from the report “9. The EpiPen box does not contain these instructions on the outside .
” 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 Present the standardized allergy action-plan process to the paediatric team through departmental clinical governance.
Verbatim wording from the response “This information has been presented to the Paediatric team in the Departmental Clinical Governance meeting on 26 June 2019.” Source location 2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Require clinical review of patients for time-critical appointments before cancelling clinics and arrange an appropriate alternative appointment.
Verbatim wording from the response “3. Re-booking cancelled clinics
The relevant department has been advised that before a clinic list is cancelled (when there are patients already in the list), the clinician is given the list of patients of the clinic who then looks through to see if any of the appointments are “time critical” (as it was in Karanbir’s case) and then instructs the secretary or access centre to send out the appropriate alternate date for the next appointment.” Source location 2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Provide two adrenaline auto-injectors for the child and two for the school, with GPs asked to prescribe four or, where applicable, three devices.
Verbatim wording from the response “4. Availability of two adrenaline auto-injectors
The Trust has made changes in that there will be two adrenaline auto-injectors to be kept with the child at all times and two to be kept at the school, so GPs will be asked to prescribe 4 adrenaline auto-injectors . The GP will be asked to prescribe 3 adrenaline auto-injectors if it is known that the school has a generic adrenaline auto-injector for use for any child.” Source location 2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Use and advocate a standardized BSACI allergy action plan, providing copies for home, school, GP, and clinical records.
Verbatim wording from the response “1. Standardized allergy care plans
Following this case, the paediatric allergy leads from Ealing and Northwick Park Hospital advise that they use and advocate the BSACI Allergy Action Plan for any child with an allergy – which is printed in colour from clinic and 2 copies are given to parents (one to be kept at home and one for them to share with the school nurse or welfare officer of the school), and this is shared with the GP and a copy is left in the clinical records.” Source location 2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Post or email each allergy action plan directly to the relevant school.
Verbatim wording from the response “2. Sharing of the allergy care plan with the school
I have been advised by the clinicians that the usual practice is training the parent (and child) first and informing them to tell the school of the child’s allergy and avoidance of the precipitant. Following Karanbir’s inquest, the Trust has added the additional process of posting or emailing each allergy plan to the school in question.” Source location 2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
Open published response
26 Feb 2019 John Thorp · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Inconsistent prescribing of TED stockings across treatment areas View source Lack of a facility for recording administration or non-administration of TED stockings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Thorp · 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
John Thorp became seriously ill with pneumonia, required intensive care and ventilation, and later suffered a cardiac arrest from which he could not be resuscitated on 8 February 2018. The inquest identified inconsistency in the prescribing and recording of TED stockings, which may lead to stockings being prescribed but not given and may increase the risk of thromboembolic formation.
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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent prescribing of TED stockings across treatment areas
Wider context from the report “(1) Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED stockings in the three different areas where Mr Thorp was treated. The standard ward based drug chart had a tick box in the low molecular weight heparin box on the drug chart for whether TED stockings were indicated.
(2) Evidence was given at the inquest that the medical staff where inconsistent in how they prescribed TED stockings . One of Mr Thorp’s drug charts had simply a tick in the box indicating there were required but there was nowhere for nursing staff to sign if they were given. Another drug chart had a separate prescription with the stockings being written up as a regular item and nurses could fill in the prescription chart to indicate if they had been given, or if not given the reasons why not.
(3) There was evidence given that this inconsistency in the way in which medical staff prescribed TED stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation.
” 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 London North West University Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for recording administration or non-administration of TED stockings
Wider context from the report “(1) Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED stockings in the three different areas where Mr Thorp was treated. The standard ward based drug chart had a tick box in the low molecular weight heparin box on the drug chart for whether TED stockings were indicated.
(2) Evidence was given at the inquest that the medical staff where inconsistent in how they prescribed TED stockings. One of Mr Thorp’s drug charts had simply a tick in the box indicating there were required but there was nowhere for nursing staff to sign if they were given . Another drug chart had a separate prescription with the stockings being written up as a regular item and nurses could fill in the prescription chart to indicate if they had been given, or if not given the reasons why not.
(3) There was evidence given that this inconsistency in the way in which medical staff prescribed TED stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation.
” 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 Disseminate TED stocking prescribing and checking instructions to clinical staff through area-specific memos, junior-doctor education, the Trust newsletter and desktop screensavers.
Verbatim wording from the response “The actions required have been shared by way of memos to all clinical staff. Junior Doctors have received the instructions via the Medical Education Department. Three separate memos were created to ensure the different clinical areas received the information to be acted upon.” Source location 2019-0067-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Implement a Trust-wide standardised prescription chart with dedicated TED stocking prescription and daily nursing checks of fitting and skin integrity.
Verbatim wording from the response “The Trust has formulated a new, standardised prescription chart to be used across the Trust. The new chart has a section for the prescribing of TED stockings.” Source location 2019-0067-Response-by-London-North-West-University-Healthcare-NHS-Trust
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 Add prescription-chart completion checks to Matrons’ Quality Walkabouts for auditing and monitoring.
Verbatim wording from the response “This has also been included as part of the Matron’s Quality Walkabout for auditing and monitoring to ensure that this section is being completed by the doctors and nurses.” Source location 2019-0067-Response-by-London-North-West-University-Healthcare-NHS-Trust
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations