Recipient

Recipient name withheld

Pin Request correction

First report 10 Jun 2022•Latest report 10 Jun 2022

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 Recipient name withheld 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

    Hollie Anne RICHARDSON · 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

    Hollie Anne RICHARDSON, who was 26, died at Luton and Dunstable Hospital on 27 November 2019 after suffering a cardiac arrest secondary to a massive pulmonary embolism. She had protein S deficiency and a strong family history of blood clots, including fatal cases. The principal concern was that patients diagnosed with protein S deficiency may not be given sufficient information or surveillance about other factors that could increase thromboembolism risk, leaving them potentially unaware of actions to mitigate that risk.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform patients with Protein S deficiency about factors that may exacerbate thromboembolism risk

    Wider context from the report

    “I heard expert evidence during the course of the Inquest relating to the management ( or lack of) following Hollie's diagnosis of being heterozygous for Protein S deficiency. My expert told me in written evidence that "There was no indication for Hollie to be reviewed periodically as the advice not to receive anticoagulant medication would not have changed unless she had a thrombotic event. If she had a thrombosis then she should have been reviewed by a haematologist to consider long term anticoagulation". The difficulty with this is that the expert acknowledged that other life events may alter the risk of thromboembolism. In Hollie's case, there was a very strong family history of protein S deficiency and of some of those suffering from blood clots including fatalities. In addition, Hollie was considerably overweight and seemingly was unaware of the increased burden of thromboembolic events this conferred on her. Counsel for Hollie's family, correctly in my view, pointed to a lacuna in the management of protein S deficiency where patients were given the diagnosis but had no reasonable knowledge of what might exacerbate this risk (because they are not told or under surveillance) so they were blind to actions that they may take to mitigate the risk. That places the responsibility for management of other risk factors squarely with the patient, who might well be ignorant of them, rendering such a position potentially hazardous. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to periodically review patients with Protein S deficiency for changing thromboembolism risk

    Wider context from the report

    “I heard expert evidence during the course of the Inquest relating to the management ( or lack of) following Hollie's diagnosis of being heterozygous for Protein S deficiency. My expert told me in written evidence that "There was no indication for Hollie to be reviewed periodically as the advice not to receive anticoagulant medication would not have changed unless she had a thrombotic event. If she had a thrombosis then she should have been reviewed by a haematologist to consider long term anticoagulation". The difficulty with this is that the expert acknowledged that other life events may alter the risk of thromboembolism. In Hollie's case, there was a very strong family history of protein S deficiency and of some of those suffering from blood clots including fatalities. In addition, Hollie was considerably overweight and seemingly was unaware of the increased burden of thromboembolic events this conferred on her. Counsel for Hollie's family, correctly in my view, pointed to a lacuna in the management of protein S deficiency where patients were given the diagnosis but had no reasonable knowledge of what might exacerbate this risk (because they are not told or under surveillance) so they were blind to actions that they may take to mitigate the risk. That places the responsibility for management of other risk factors squarely with the patient, who might well be ignorant of them, rendering such a position potentially hazardous. ”
    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