Luton and Dunstable University Hospital NHS Foundation Trust

Health and care · NHS trust

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First report 16 Apr 2014•Latest report 16 Apr 2014

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
1

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 Luton and Dunstable University Hospital NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    Sari Marlene KEEN · 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

    Sari Marlene KEEN underwent surgery to remove colon tumours on 23 October 2013, developed a faecal anastomotic leak causing peritonitis and shock, and died following cardiac arrest on 24 October 2013. The substantive concerns were insufficient staffing and failures to recognise deterioration, escalate care, and call the Hospital Crash Team when her blood pressure became unrecordable.

    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 Luton and Dunstable University Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of sufficient staffing for patient caseloads

    Wider context from the report

    “(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”
    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 Luton and Dunstable University Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call

    Wider context from the report

    “(2) It was apparent that many Senior and Junior Members of Staff were not aware that an ‘un-recordable blood pressure’ was a ‘medical emergency’ and should have resulted in a crash call going out for immediate resuscitation. Perhaps the Protocols for the Crash Team need to be reviewed. ”
    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 Luton and Dunstable University Hospital NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate care when overwhelmed

    Wider context from the report

    “(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”
    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