Recipient

Queen Elizabeth Hospital, Woolwich

Pin Request correction

First report 7 Feb 2020•Latest report 7 Feb 2020

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 Queen Elizabeth Hospital, Woolwich linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Mr Adrian Ashford · 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

    Mr Adrian Ashford died in Queen Elizabeth Hospital on 15 December 2018 after a massive upper gastrointestinal bleed, with the medical cause of death recorded as upper gastrointestinal bleeding due to chronic peptic ulcer. Concerns included the absence of a systematic process for recording weights and failures to identify or respond to risks of gastrointestinal bleeding, including consideration of gastroenterology referral.

    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 Queen Elizabeth Hospital, Woolwich; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a systematic process for recording weights

    Wider context from the report

    “1. ████████ GP and ████████ Divisional Medical Director, both gave evidence of the value of having some system for regular weighing, and that it might save lives. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights. ”
    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 Queen Elizabeth Hospital, Woolwich; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify risks of gastrointestinal bleeding and reasons for urgent transfer

    Wider context from the report

    “2. The consultant in acute medicine, who was on call when Mr Ashford was admitted to A&E on 11th December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in A&E on 11th, nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14th he also failed to consider referral to a gastro-enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness. ”
    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 Queen Elizabeth Hospital, Woolwich; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider gastroenterology referral after clinical deterioration

    Wider context from the report

    “2. The consultant in acute medicine, who was on call when Mr Ashford was admitted to A&E on 11th December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in A&E on 11th, nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14th he also failed to consider referral to a gastro-enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness. ”
    Open source report
Back to top

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