Recipient

Parents of Kinga Cieciorska

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First report 13 Jun 2016•Latest report 13 Jun 2016

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Parents of Kinga Cieciorska linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Black Country

    AI-generated summary

    Kinga Cieciorska · 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

    Kinga Cieciorska, a 16-year-old girl with complex medical needs, was taken to hospital with abdominal pain and distension. She was diagnosed with constipation and discharged, but deteriorated overnight and died after being returned to hospital on 11 March 2016; the stated cause of death was peritonitis from a perforated gastric ulcer. Concerns included failure to investigate tachycardia and an abnormal ECG, failures in recording and transmitting clinical information, and failure to consider the significance of her medication.

    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 Parents of Kinga Cieciorska; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider medication details and the significance of diclofenac

    Wider context from the report

    “3. It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered. One of the contra-indications of this drug for long term users is gastric ulcers. Many people take NSAIDs without having any side effects, but there's always a risk the medication could cause problems, such as stomach ulcers, particularly if taken for a long time or at high doses. ”
    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 Parents of Kinga Cieciorska; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to forward and make available GP medical notes for clinical examination

    Wider context from the report

    “2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of the patient. ”
    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 Parents of Kinga Cieciorska; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record the identity of the specialist clinician giving advice

    Wider context from the report

    “2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of the patient. ”
    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 Parents of Kinga Cieciorska; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to investigate abnormal ECG findings and tachycardia through further testing and observation

    Wider context from the report

    “1. Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed further investigation and she should have been subject to further tests and admitted for further observation to establish the cause of the tachycardia. This was effectively a missed opportunity to render basic medical care. On the balance of probability it is more likely than not, she may have survived or life may have been extended if tests had been done to confirm the diagnosis of peritonitis and appropriate treatment commenced. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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