National Patient Safety Alerting Committee

Private and voluntary organisations · Health professional committee

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First report 2 Aug 2023•Latest report 2 Aug 2023

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 National Patient Safety Alerting Committee linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    Dumile Daniel Thompson · 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

    Dumile Daniel Thompson developed Ramipril-induced angioedema, deteriorated after an apparent initial improvement, suffered respiratory collapse causing catastrophic brain injury, and died several days later after life support was withdrawn. The principal concerns included inadequate recognition of the risks and trajectory of ACE inhibitor-induced angioedema, insufficient specialist airway reassessment and monitoring, lack of relevant guidance and training, and limited access to previous medical records affecting medication decisions.

    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 National Patient Safety Alerting Committee; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to highlight the preferred ARB recommendation for patients of Black African or African Caribbean origin in the BNF

    Wider context from the report

    “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
    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 National Patient Safety Alerting Committee; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to publish the increased ACE inhibitor angioedema risk for people of Black African or African Caribbean origin in the BNF

    Wider context from the report

    “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
    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 National Patient Safety Alerting Committee; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of frontline emergency staff training on angioedema types, risks and divergent treatment pathways

    Wider context from the report

    “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
    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 National Patient Safety Alerting Committee; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of NICE emergency management guidance or clinical knowledge summary for angioedema

    Wider context from the report

    “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
    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 National Patient Safety Alerting Committee; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make previous medical records available to clinicians in different geographical areas or Trusts

    Wider context from the report

    “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
    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