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First report 21 Oct 2020•Latest report 9 Dec 2025

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
2

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 Maylands Health Care linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Urielle Mayila Kuyenga · 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

    Urielle Mayila Kuyenga, a four-year-old girl with sickle-cell disease, died in hospital on 4 December 2023 from sepsis resulting from bacterial pneumonia. The report identifies failures to ensure administration of prescribed prophylactic penicillin and failures by doctors to identify her sickle-cell diagnosis during three presentations for respiratory infection as contributory factors.

    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 Maylands Health Care; that does not assign responsibility.

    PFD Monitor interpretation

    Breakdown of communication about responsibility for penicillin prescription and dispensation

    Wider context from the report

    “1. As a patient with Sickle Cell Disease, Urielle was prescribed prophylactic penicillin to mitigate the risk of her developing fatal symptoms arising from typical respiratory infections. Urielle’s mother chose not to collect those prescriptions and administer penicillin to Urielle. While specialist doctors believed that her GP was monitoring the prescription and dispensation of the penicillin, whilst Urielle’s GP was misled by Urielle’s mother that the hospital were dispensing the medication directly. The breakdown of communication means that Urielle was left unprotected from opportunistic infection which caused this avoidable death. ”
    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 Maylands Health Care; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of clinicians to identify Sickle Cell Disease from available clinical records

    Wider context from the report

    “2. In the weeks prior to her death Urielle’s mother presented her daughter to three separate GPs about a respiratory infection. On each of these three attendances the attending clinician was ignorant of Urielle’s Sickle Cell diagnosis. The reasons for these lapses were, firstly Urielle’s mother did not inform the doctor of the fact and, second, that the doctors did not adequately read the clinical records available to them. ”
    Open source report

  2. East London

    AI-generated summary

    Roger Wood · 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

    Roger Wood had been monitored for an abdominal aortic aneurysm, which measured 5.5 cm in June 2017. The scan result was sent to his GP but was not acted upon, and he was not referred for specialist treatment. He later died from a fatal rupture of the aneurysm on 12 February 2019. The principal concern was that the treatment pathway relied on a GP referral link that could fail, allowing vital diagnostic information not to be acted upon.

    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 Maylands Health Care; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on GP assessment and referral within the AAA treatment pathway

    Wider context from the report

    “In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient’s GP for assessment. The GP was to decide whether to refer the patient for treatment. In Mr Wood’s case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result. In the light of the sad facts of Mr Wood’s death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include auto mailed to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral. My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood’s case, is capable of failure. ”
    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